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High Twelve Membership Application
Click here for a printable version of this application.

DATE___________________

MY NAME IS_____________________________________________

I'M A MEMBER IN GOOD STANDING OF THE ________________

__________________ MASONIC LODGE NO.______ located in

___________________________________________AND WISH TO

APPLY FOR MEMBERSHIP IN THE ________________________

___________________________ HIGH TWELVE CLUB OF______

_______________________________________________________

IF ACCEPTED FOR MEMBERSHIP IN HIGH TWELVE, I PROMISE

TO GIVE MY BEST INFLUENCE AND EFFORTS FOR ITS ADVAN-

CEMENT AND AGREE TO ABIDE BY ITS CONSTITUTION AND

BY-LAWS, INTERNATIONAL, STATE AND LOCAL

SIGNATURE OF APPLICANT_______________________________

PERSONAL DATA

FULL NAME______________________________________________

RESIDENCE ADDRESS_____________________________________

STATE________ZIP CODE_________PHONE___________________

BUSINESS ADDRESS______________________________________

STATE________ZIP CODE_________PHONE___________________

NEXT OF KIN OR FRIEND __________________PHONE  _________

OCCUPATION - IF RETIRED, SO STATE, AND GIVE FORMER

OCCUPATION_____________________________________________

YOUR NICK NAME___________________ DATE OF BIRTH________

WIFE'S NAME_______________________ DATE OF BIRTH________

ANNIVERSARY DATE ______________________

Interested in forming a new club? Write:

High Twelve International
2412 Grant Street
Bettendorf, IA 52722