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Text Box: CANDIDATE PLEASE ANSWER First Name: ________________________________ Middle Name: ______________________________ Last Name: ________________________________ Mailing Address: ____________________________ Street or Ave.: ______________________________ Rural Route Box No.: ________________________ City :______________________________________ State: _____________________________________ Zip Code: __________________________________ Date of Birth: __________________(month/day/year) Place of Birth: _______________________________ (Give detailed information about occupation, if merchant, what kind of merchant, what kind of engineer, salesman, plumber, manager, etc.) Telephone: Home:__________________________ Work: __________________________ Cell: ____________________________ Email: ____________________________________ Occupation: ________________________________ Spouses Name:______________________________ If retired, occupation before retiring:____________________________________________________________________________________ Employer (note if self employed):__________________________________________ Blue-Lodge Name: __________________________ No.: ________ City: ________________________________ State: ________________________________

Text Box: I am a Master Mason in good standing, eligible to petition for the Scottish Rite Degrees, (if a member of a South Dakota Lodge, I have proved up on the Master Mason Degree) reside as shown below and am a qualified voter of such state. I have never applied for any of the Scottish Rite Degrees and I now respectfully petition to receive the degrees from the 4th to the 32nd inclusive, promising always to bear the true faith and allegiance to the Supreme Council of the Thirty-third Degree for the Southern Jurisdiction of the United States. 1. The Supreme Council announces as fundamental principles the following: *The inculcation of patriotism, respect for law and order and undying loyalty to the principles of civil and religious liberty and the entire separation of church and state as set forth in the constitution of the United States.* Do you approve wholeheartedly of these principles?_______________________ 2. Have you ever held or expressed opinions contrary to the foregoing or been affiliated with any organization that has?_____ If you answer in the affirmative, give particulars:___________________________________________________________________________________________________________________________ Recommended by: ___________________________ ___________________________ Usual Signature of Petitioner:_________________________________ Date:

Text Box: FEES: For the degrees from 4th to 32nd, $175. If under age of 31 at the date of initiation $100. A deposit of $50 must accompany petition. Flexible payment plans are available for the balance. We also accept VISA, MasterCard or Discover payment in person or by phone. Please complete this petition and mail check and Petition to: Yankton Scottish Rite, PO Box 124, Yankton, SD 57078, Lodge phone number 665-2414 Any Master Mason may apply for the degrees for the Scottish Rite provided he is in good standing, has proved up to the Master Mason degree, and is recommended by two Members of the Rite.

Text Box: Payment Options & Amount Paid: Cash $_________________ Check $_________________ Visa $_________________ MasterCard $_________________ Discover $_________________ Card Number:______-_______-______-______ Exp. Date: _________ Last 3 Digits on Back of Card: _________ Signature:______________________________

Text Box: Date Received: ___________________ Date Elected: