MOST WORSHIPFUL PRINCE HALL GRAND LODGE F. & A.M.
ARIZONA AND JURISDICTION, INC.
PETITION FOR REINSTATEMENT
To the Worshipful Master, Wardens and Brethren
LODGE NAME_________________________________________ NO.___________ F.& A.M
Working under a regular Charter from the Most Worshipful Prince Hall Grand Lodge, F. & A.M. of
Arizona and its Jurisdiction, Inc.
The Subscriber ______________________________________, has being regularly initiated, passed and
raised to the Sublime Degree of Master Mason and was a member of this Lodge. Having paid all dues,
fees and assessments as required by the Constitution and Masonic Code of the Jurisdiction of Arizona and
having otherwise complied with all legal requirements of the Lodge. The undersigned hereby applies for
Reinstatement to the Active Lodge Roll.
Address City, State, Zip
Daytime Phone Home Phone
Born in ______________________________ on the _____ day of _______________________, _______
If the prayer of this petition is granted, Petitioner promises a cheerful obedience to the laws and
regulations of the Lodge, and full compliance with the usage’s and customs of the Fraternity.
Date of Suspension Health Certificate is attached.
If over 60 years of age you are not required to donate to the Charity Fund and must waive your rights to
the donation, in which case a physical examination is not required. Yes_____ No ____
Dated at ___________, This_____ day of _______________, 20 ____
Give the Name of Wife or Next Nearest Relative
We, the Worshipful Master, Wardens and Members of __________________________________ Lodge,
No. _______, Free and Accepted Masons, accepted this request for reinstatement at our regularly
scheduled communication on ,
Age __________Residence _________________________________________________
Business___________________________________ at ___________________________
EXAMINATION OF APPLICANT
This is to certify that I have examined Mr. _____________________________________
and find the following:
Temp ______ Pulse _______ Does it intermit or become irregular? __________________
Is respiration steady, full, free, distinct in both Lungs? ____________________________
Any evidence of pulmonary disease? _______________ Or of heart disease? __________
Any indication of any disease of the brain? _____________________________________
Have you examined the urine? ___________________ Is it free from Albumen? ________
From Sugar? ______________________________________________________________
Do you find applicant’s condition as stated in his answers? __________________________
Do you find any condition of disability as stated in his answers? ______________________
Do you find evidence of Syphilis? _________ Cancer? _________ Phthisis? ____________
Is applicant addicted to stimulants or drugs? ______________________________________
Do you consider the applicant to be in a state of health and able to earn a livelihood? ______
Is there a health reason why applicant should not be accepted for membership in the order?
TO THE WORSHIPFUL MASTER, WARDENS AND BRETHERN OF
_____________________________________ No. ______________ F.& A.M.
The undersigned, your committee, to whom was referred the petition of
_____________________________________________________ Praying to become a member of this lodge,
wish to report that they have made necessary inquiries about his habits, moral character and standing, and report
unfavorable/favorable to his admission.