To the Ansar Shriners Units:

I hereby make application for membership in a Uniformed Unit of Ansar Shrine and submit the following
for consideration:

(Use this area if you currently do not belong to a uniformed unit)
I HAVE NO PRIMARY UNIT NOW AND AM APPLYING FOR:  

(Use this area if you want to transfer primary membership to another uniformed unit)
My current unit is:  
I want to join:

Name:

DOB:

Address:

Email address:

Spouse's name:

Phone number:

Employer:

Occupation:

Work phone:

MILITARY SERVICE: YesNo

(For Legion of Honor applications, upload a copy of your Dept of Defense Form DD-214 here)

By signing I further submit that I will abide by the rules and regulations of the Ansar Shrine Council of Uniformed Units and with the Constitution and By-Laws of the uniformed unit of application. I will properly care for Ansar property and upon request will return any property issued to me for parade and/or other uses. I understand it is possible to be a participating member of other units; however, I will parade with my primary unit and will have voting rights determined by the By-Laws of each unit. I am a member in good standing of Ansar Shrine in the city of Springfield, Illinois, USA.

For U/U Use Only: (___) Elected (___) | Rejected Date: ________________ Initials: _______________