ANSAR SHRINERS

Name

To the Potentate, officers and Nobles of Ansar Shrine, situated in the Oasis of Springfield,
Desert of Illinois.
          I, the undersigned, a former member of Ansar Shrine and now under the sentence of
because of respectfully request that
I may be restored to membership.
          I have liquidated all indebtedness to the Temple and if my request is granted, I promise
to conform to the articles of incorporation and bylaws of the Imperial Council and Ansar Shrine.
I furthermore declare that I am a Master Mason in good standing in
Lodge # located in
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Profession:
Address:
Business Address
Phone Number: Business Phone:
Email address:
Spouse’s name:
Date:

Recommended By:
Noble: Member Number:
Noble: Member Number: