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APPLICATION FOR HONORARY PERPETUAL MEMBERSHIP This is to certify that I, ___, hereby make application (print FULL name×for an Honorary Perpetual Membership in ___ Lodge # ___ in the name of ___.

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What is please type or print?

Please provide the information requested in the form by typing or printing clearly.

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Individuals or entities designated in the form instructions are required to file.

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Follow the instructions provided in the form and provide all requested information by typing or printing neatly.

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The purpose of this form is to gather specific information required for reporting purposes.

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