ANSAR SHRINE
SPRINGFIELD, ILLINOIS

To the Illustrious Potentate, officers and Nobles of Ansar Shrine,

I, the undersigned, a Noble of the Mystic Shrine, initiated at Shrine, located at
, on (date) and last, a member of Shrine,
located at , which has granted the attached certificate of demit, respectfully pray
that I may be admitted a member of your Shrine Center. I furthermore state I have not been suspended
or expelled from the Masonic Lodge, which is the prerequisite to membership in the Shrine, since the
date of issuing the demit. Presented herewith. I furthermore state I have resided within the jurisdiction
of your Ansar not less than six months, as required by the by-laws of the Imperial Council.

I am a Master Mason in good standing in Lodge # located at
  .

Other Masonic Memberships:
Scottish Rite Valley Location
York Rite Commandry Location
Profession or Occupation
Birthplace Date of Birth
Address
Business Address
Home Phone Business Phone
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Date July 1, 2026 

Full name

Recommended and vouched for by:
Noble Member Number
Noble Member Number

Date affiliated