New Member by Affiliation Form
Grand Lodge A. F. & A. M. of North Dakota
Lodge name:
No:
Member's name:
(Last)
(First)
(Middle)
Address:
City, State, Zip:
,
Date of Birth:
Place of Birth:
Name of Spouse:
Phone Numbers:
Home
Work
Cell
E-mail Address:
Occupation:
Check one of the following
Reinstatement:
Plural (ND):
Dual (Another State):
By Demit or Certificate of Good Standing from another Lodge:
If by Demit or Certificate from another Lodge, Dual or Plural Membership, give name and location of
Original Lodge:
City Of:
State:
Date of Change:
Submitted By: