ANSAR SHRINERS
Name
To the Potentate, officers and Nobles of Ansar Shrine, situated in the oasis of Springfield,
Desert of Illinois.
I, the undersigned, hereby declare that I am a Master Mason in good standing in
Lodge # , A.F&A.M., located in
which is a Lodge recognized by or in amity with the conferences of Grand Masters of North
America. A copy of my current dues card is submitted as proof. Furthermore, I have resided at
my current address for not less than six months, as required by the bylaws of the Imperial
Council and that I am not under suspension or expulsion in the Masonic body prerequisite to
the Order. I respectfully pray that I may be made a Noble of the Mystic Shrine, and become a
member of Ansar Shrine.
If I be found worthy, and my request granted, I promise to conform to the article of
incorporation and bylaws of the Imperial Council and the bylaws and ceremonies of Ansar
Shrine.
Birthplace: Date of Birth:
Were you in DeMolay? Chapter/Location:
Scottish Rite Valley: Location:
York Rite Commandry: Location:
Have you previously applied for admission to any Shrine Temple?
If so, what Temple?
When?
Profession:
Address:
Business Address:
Home Phone:
Business Address:
Email Address:
Spouse’s Name:
Fez Size:
Date:
July 1, 2026
Full Name: Other Names, if any:
Recommended and vouched for by:
Noble Member #
Noble Member #
2025 Ceremonial Dates
June 14, 2025 – Paris, Illinois
December 6, 2025 – Springfield, Illinois
2025 Prices
Without Fez - $289.00
With Fez - $124.00
Credit Card Info:
Credit Card Number:
Expiration date:
