To the Worshipful Master,
Officers and Members of

Lodge Name____________________________________Lodge No.________

Free and Accepted Masons of Pennsylvania

I, the undersigned, respectfully pray that I may be Initiated into the mysteries of Freemasonry and become a Member of your Worshipful Lodge.

I declare that I am free by birth, unbiased by the improper solicitation of friends, and uninfluenced by mercenary or other improper motives; that I am prompted solely by a favorable opinion conceived of the Institution, and a desire of knowledge; and that I freely and voluntarily offer myself as a Candidate. I further declare my belief in the existence of a Supreme Being; that I have never before Petitioned any regularly Constituted Masonic Lodge to be made a Mason and been rejected; and that, if my Petition is approved, I will conform to the Ancient Usages and Customs of the Fraternity.

Name in full	______________________________________________ (Give First and Middle Names in Full)
Age______	Date of Birth ____________	S.S.#_________________
Occupation	______________________________________________ (State specifically and in detail the character of the occupation)
Residence	______________________________________________ (Give Street and Number)
City _____________	State________	Zip___________
County _____________		Telephone_____________
Where I have continuously resided since_______________
My Former Residences were:
at___________________________________for_________		years, and
at___________________________________for_________		years.
Place of Birth	_______________________________________ (City) (State) (County)
Name of Employer	___________________________________________
Business of Employer	___________________________________________
Signature of Petitioner	___________________________________________
Date of Signature	___________________________________________
Are you a Senior DeMolay? yes ____ no_____
I recommend the Petitioner as worthy and certify that I have been personally acquainted with him immediately preceding this date.
________________________________________ Signature of member of this Lodge		Date ____________
I recommend the Petitioner as worthy and certify that I have been personally acquainted with him immediately preceding this date.
________________________________________ Signature of a Pennsylvania Mason		Date ____________
The Committee appointed on the within Petition of
________________________________________ Full Name of Petitioner
to make the necessary inquiries relative to his fitness for Initiation as a Freemason and for membership in this Lodge, hereby certifies that at least one of the undersigned has personally interviewed the Petitioner at his home, has read to him the Petition, and has inquired whether he subscribes to all the conditions thereof. The committee has made a diligent and careful inquiry as to all matters which pertain to the character and residence of the Petitioner and reports
_____in favor of _____ not in favor of
the Prayer of his Petition being granted.
Witness our hands this__________________day of _______________ A.D. ______, A.L.____________.
Committee
X____________________________________ Chairman
X____________________________________
X____________________________________

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