Complete this petition and deliver or mail it with your check in the total amount of dues to the Secretary of your local Scottish Rite. Please make check payable to your (Valley) Scottish Rite, ex. Baker Scottish Rite.

Contact your local Valley Secretary (listed below)  for Initiation Fee and Valley Dues.

Fees/Dues Attached: ______

Current Address: __________________________________C/S/Z_____________________

Phone: ____________________________

E-mail Address: ___________________________

Date of Birth: _____________________________Place of Birth: ________________________

Blue Lodge: ____________________No. ___________at: ______________________________

Date Raised: _______________________________

3° Proficiency: _____________________________________

Occupation (If retired, list last occupation/Retired) ____________________________________

I have resided in ________ County for _______ years ______ months. (Cap size: ________)

Marital Status/ Wife’s name? ___________________

Have you ever petitioned for any of the Scottish Rite Degrees? ___________________

I approve wholeheartedly the following principles: “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 of America.”

I have never held or expressed opinions contrary to the foregoing or been affiliated with any organization which has.

I respectfully petition to receive degrees 4° to 32° inclusive, promising always to bear true faith and allegiance to the Supreme Council of the Thirty-Third Degree, for the Southern Jurisdiction of the United States of America. The statements in this petition are on my honor as a Mason.

____________________________Signature

________________________________________ Mailing Address (if different than above)

Recommended by: *

1.____________________________________________  2.___________________________________________

* Must be members in good standing of an Oregon Valley

Telephone Numbers of the Secretaries of the Oregon Valleys:

Baker               541-534-5501

Coos Bay          541-269-9663

Eugene             541-344-1288

Medford           541-772-2205

Pendleton         541-567-2565

Portland           503-226-7827

Klamath Falls   541-882-1571

Roseburg          541-672-1736

Salem               503-363-9240