4th Degree Online Membership Application Submission

Member Number:

Last Name:

First Name:

Middle Initial: (Optional)

Title: (Optional)

Street:

City:

State:

Postal Code:

Phone Number:

Email Address:

Date of Birth:

Marital Status:

Council Number:

Council Number: (Please reselect same Council Number as above)

Parish:

Proposer First and Last Name: (if known)

Proposer Assembly Number: (if known)

Proposer Member Number: (if known)

Additional Comments: (Optional)

Enter the Recaptcha Code from the image on the right in the box below before clicking submit. If you are receiving an error that you cannot continue try to refresh the Recaptcha code by clicking Change Image and enter the new one that comes up and click Submit.

Recaptcha CAPTCHA Image Change Image

Please wait about 30 seconds to 1 minutes after clicking the submit button for the email to be sent. Please make sure to wait for the email to come to you and could be up to 2 to 5 minutes. This will ensure your 4th Degree Application is submitted correctly.