No.____________

To the Potentate and Nobles of Oasis Shriners, situated in the Oasis of Charlotte, Desert of North Carolina:

I, the undersigned, hereby declare that I am a Master Mason in good standing in _________________________ Lodge No.________ A. F. & A. M. located at _______________________________________.

Furthermore, I do not now, and never will, hold membership in or allegiance to, any Body claming to Be Masonic that has been declared clandestine by a Commandery or Perceptory of Knights Templar of the United States of America, or Consistory of the Ancient and Accepted Scottish Rite in the United States, of Free Masonry of the obedience of either the Supreme Council of the Northern of the Southern Jurisdiction of such Rite in the United States, of a Supreme Council in amity with and recognized by the By Laws of the Imperial Council, and that I am not under suspension or expulsion in any of the Bodies prerequisite to this Order, and respectfully pray that I may be made a Noble of the Mystic Shrine, and become a member of your Chapter.

If I be found worthy, and my request granted, I promise to conform to the Articles of Incorporation and By Laws of the Imperial Council and the By Laws and Ceremonies of Oasis Shriners.

Birthplace ______________________________Date of Birth______________________

Profession __________________________ Name of Firm_________________________

Your Position ________________________Wife’s Name__________________________

Business Address _______________________City__________________Zip_________

Residence Address ______________________City__________________Zip_________

Business Telephone _____________________Home Telephone____________________

Fax No.: ______________________________ Cell Phone:________________________

E-mail address: _____________________________

Send mail to: [ ] Residence [ ] Business Hat Size____

Have you previously applied for admission to any Shrine Chapter or Order? ____________________

When? _________ Were you ever DeMolay [ ] Yes [ ] No. If so, what was your Chapter or Order?

_____________________________________ Where?___________________________

Print your name in full (do not use initials) _________________________________________________

Date: ___________________ Signature ____________________________________________________

Recommended and vouched for on the honor of:

Noble ___________________________________ Shrine No. ___________ Club/Unit_______________

Remittance to accompany this application – payable to Oasis Shriners, $200.00. Return to: Oasis Shriners, P. O. Box 560666, Charlotte, NC 28256-0666.

Or Charge To: (Check One) MasterCard, Visa, Amex, Discover Card #: _______________________

Expiration Date: _______________ Name on Card (if other than yours) :____________________