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PETITION FOR REINSTATEMENT Prince Hall Grand Lodge of Arizona

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PETITION FOR REINSTATEMENT Prince Hall Grand Lodge of Arizona Powered By Docstoc
					            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

Email                                                         Occupation

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 ____


Signature _______________________________________________

Dated at ___________, This_____ day of _______________, 20 ____


Give the Name of Wife or Next Nearest Relative


_________________________________________
Relation

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                                        ,

Fraternally,

                                           Worshipful Master

                                           Secretary
                                                    MEDICAL EXAMINATION


                    Name __________________________________________________________________

                    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?

                  ___________________________________________________________________________

                                                             Remarks:



                  Date _______________________________________________________________________


                  _______________________________________________________________________ M.D.



            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.

__________________________________                     __________________________________

                             ________________________________

				
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posted:12/5/2011
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