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PETITION FOR INITIATION AND MEMBERSHIP

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? YesNo

If so, what Temple? When?
Profession:
Address:
Business Address:
Home Phone: Business Address:
Email Address:
Spouse’s Name: Fez Size:
Date: May 20, 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: VisaMastercardDiscover

Credit Card Number:
Expiration date:

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Timestamp

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August 15, 2025 1:16 pm CDT

PETITION FOR INITIATION AND MEMBERSHIP Uploaded by Tony Moore - ansaroffice@ansarshrine.com IP 140.141.212.112