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Ancient and Accepted Scottish Rite of Freemasonry
Southern Jurisdiction of the United States of America
Orient of Wyoming - EHC Valley of Lander

DATE: ___________________,20___________

I am a Member in Good Standing in ___________________________________________________ Lodge No.____________
Located at ____________________________________, operating under the Grand Lodge of ________________________
I was born ___________________________________ at_____________________________________________________                              Month, Date, Year                                                    City or Town, State
I currently reside at___________________________________________________________________________________                                           Number & Name of Street                                      City or Town, State Zip Code
Phone Number__________________________ Email_________________________________________________________
I have been a resident of this state for the past 6 months. My Occupation is______________________________________or
was before retirement, in employment of/or connected with____________________________________________________ Height is _____ft ____in, Color of eyes _____________; Color of Hair;__________Hat Size__________Ring Size__________
My mailing address is ___ same as above, or _______ Different from residence
(if different, please list here)_____________________________________________________________________________

The following statements of Principle are essential as a basis for consideration of this application:

1."The inculcation of patriotism, respect for law and order and undying loyalty to the Constitution of the United States of
2 " The entire separation of Church and State and opposition to every attempt to appropriate public monies, federal, state, or

local, directly or indirectly, for the support of sectarian or private institutions"
Do you approve wholeheartedly of these principles? (Answer Yes or No) __________;

Have you ever held or expressed opinions contrary to the foregoing or been affiliated with any organization which

has? (Answer Yes or No) _______;
If you answer this question in the affirmative, give the particulars________________________________________________ Have you previously applied for the Degrees? ____________. If so, give the date and place where the application was made ________________________________________________________________________________________________________

I respectfully petition to receive the degrees, from 4th to the 32nd, inclusive, promising always to bear True faith and allegiance
to the Supreme Council of the 33rd degree for the Southern Jurisdiction of the United States of America.
SIGN complete given name (do NOT use initials) __________________________________________________________________________________________________ 
Name                                                                     Middle Name                                               Last Name

Type, or Print, name as signed above __________________________________________________________________________________________________ Name                                                                     Middle Name                                                Last Name

Recommended by (two members of Wyoming Scottish Rite)____________________________________________________
                                                                                            ______________________________________________ _______________________________________________________________________________________
Lodge of Perfection (4*-14*) $95.00 (At Minimum this fee is to accompany this application)
Chapter of Rose Croix (15*-18*) $25.00
Council of Kadosh (19*-30*) $25.00
Consistory (31*-32*) $20.00
Total Fees for all Bodies $160.00   
__________________________________________________________________________________________________ Official Use Only: Date Verified with Valley:_____________ Committee Members Signatures____________________________
Date Application & Payment Received:________________                                                  ____________________________ Report of the Committee ____ Favorable ____ Unfavorable                                                 ____________________________ Petition Approval Date:______________                            Date of Degrees:____________________

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