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Kentucky Colonels Shrine Club
c/o Egypt Shrine
P.O. Box 22805
Tampa, FL 33622-2805

Please print all entries except signature.

Name: _______________________________________________________________

Street Address: ________________________________________________________

City: ______________________________ State: _______ ZIP Code: ____________

Telephone Number: (_____) _______ - ______________ E-Mail Address: ___________________

Lady's Name: ______________________ #of Children: (Boys) _______ (Girls) _________

I am a member in good standing with __________________________________ Temple Shrine

Date of Kentucky Colonel Commission is: _______________________________

If accepted for membership in the Kentucky Colonels Shrine Club, I agree to abide by the bylaws of the Club together with the bylaws of Egypt Temple Shrine and the Imperial Council of the Ancient Arabic Order of the Nobles of the Mystic Shrine of North America.

Date: ____________________ Signature of Applicant:___________________________________

Recommended by: Col. ___________________________________________________________

                               Col. ___________________________________________________________             

Initiation fee of $20.00 (which includes first year dues) must accompany this application.
Annual dues are $10.00.