Petition

Present Occupation*
Name of firm (What firm do you work for or own?)
Street Address Address Line 2 City State ZIP Code
How many years & months have you lived in Indiana?*
Years
*
Months
Have you ever served in the armed forces?*
- Yes
- No

Father's Information
Father's Name
Street Address Address Line 2 City State ZIP Code
Father's Occupation
Father's Status*
- Living
- Deceased
Is (or was) your father a Mason?*
- Yes
- No
Brothers
Are (were) any of your brothers Masons?*
- Yes
- No
- I don't have any brothers
If yes, in what Lodge is/are (or was/were) his/their membership?
List the name and address of the lodge(s) your brother(s) is/are or was/were a mason(s).
Spouse
Are you married?*
- Yes
- No
Spouse's Name
First Last

If relevant, list your spouses name.
Place of Marriage
If relevant, list your place of marriage.

Places of employment for the past 10 years*
Please provide employment history.
Have you ever been denied membership in, withdrawn your petition to, or been suspended or expelled from any fraternal organization?
- Yes
- No
Details:
If you answered "Yes," please provide details about the situation.
Do you have any physical impairment?
- Yes
- No
Please let us know if you have a physical impairment or difficulty so we can make accommodations to ensure safety during the degrees.
Details of physical impairment:
If yes, please provide details.
Have you ever been convicted of a criminal offense in a court of competent jurisdiction?*
- Yes
- No
Minor traffic violations are excluded.
Conviction Details
If you answered "yes "and you have been convicted, please provide details of the circumstance.

Please provide three business or professional references we may contact, other than your petition signers.
First Refernece
Name
First Last
Phone
Email
Second Refernece
Name
First Last
Phone
Email
Third Reference
Name
First Last
Phone
Email

Every petition must be signed by two members of the Lodge you are petitioning. They must be members of Millersville Lodge
Petition Signatures*
- I have both a top-line and supporting signer
- I only have a top-line signer, and wish the secretary to request a signature from a brother.
- I don't know have either and would like the secretary to request a signature from two brothers.
If you have two members of Millersville you know, you will list them as your top-line and supporting signer. If not, we can reqeust a brother(s) to sign the petition on your behalf.
Petition for the Degrees of Masonry In Indiana

To the worshipful Master, Wardens and Brethren of
Millersville Lodge No. 126, F & A.M. Indianapolis, IN
I, the undersigned, respectfully represents that having long entertained a favorable opinion of your ancient Institution and having a belief in God, he is desirous of being admitted a member thereof if found worthy. He has resided within the jurisdiction of your Lodge for the period of years and months listed below, next preceding the date of this petition. He has not been rejected by any other Masonic Lodge within the period of one year. The character of the business in which he is engaged as proprietor or employee is also listed below.
Top-Line Signer
Top-Line Signer's Name
First Last
How long has the signer known you?
Supporting Signer
Supporting Signer's Name
First Last
How long has the signer known you?

Petition Fee*
Price: $165.00
Millersville Lodge has a petition fee of $165 which must be submitted with the petition.
Total
$0.00
Credit Card

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Millersville Masonic Lodge