AMBASSADOR’S SHRINE CLUB
4050 DANA SHORES DRIVE
TAMPA, FLORIDA 33634

MEMBERSHIP APPLICATION

(PLEASE PRINT) 

I DO DECLARE I AM AN AMBASSADOR IN GOOD STANDING IN _______________________ SHRINE. CARD No.______________ LOCATED IN THE CITY OF_________________           STATE OF______.

I AM A MEMBER IN GOOD STANDING IN BLUE LODGE ___________________ NO._______  IN THE CITY OF _______________________ STATE OF ______

NAME __________________________________________________D.O.B.                       
LADIES NAME_________________________  

NORTH ADDRESS:  STREET ____________________________________________  
CITY _____________________________STATE                          ZIP _____________

FLORIDA ADDRESS: STREET____________________________________________ 
CITY ___________________________ ZIP                          PHONE (  ) ___________

WE ARE IN FLORIDA THE MONTH’S OF ____________________________
I HAVE SERVED MY TEMPLE AS__________________________________

I HAVE SERVED IN THE FOLLOWING MASONIC OFFICES_________

MY OCCUPATION IS/WAS_______ _______
I AM RETIRED ____ YES ____ NO ___ 
I WILL BE INTERESTED IN SERVING THE CLUB AS ____________________
______________________________________________________________

  ______________________________________________________
(SIGNATURE OF APPLICANT)  

Please send your application with $10.00 dues to:
Ambassadors Shrine Club
c/o Egypt Shrine Center
P.O. Box 22805
Tampa, FL 33622-2805 

Last updated: 09/27/03