1. By signing this application, I hereby authorize the receipt of Lodge newsletters and statutorily required notices pursuant to Section 1.115 of the Grand Lodge Statues by E-mail or other electronic means at the personal E-mail address listed above.
[radio Authorize label_first use_label_element default:1 "Yes" "No"]
2. Applicant was born in the city of
Country
State
Month
Day
Year
3. Do you believe in God and you are willing to attest to that belief?
4. Are you a citizen of the United States of America?
5. If foreign born, when and where your final naturalization papers issued: Month
Year
6. Are you willing to assume an obligation that:
(a) Will not conflict with your duties to yourself, or your family, or your religious or political opinions, and that
(b) Will bind you to uphold the Constitution and laws of the United States of America?
7. Are you now a member of or directly participating in the activities of any group or organization, or supporting or adhering to beliefs or tenets advocating the overthrow of the Government of the United States or any of it's political subdivisions by force or violence?
8. Have you ever pleaded guilty or no contest to or been convicted of a felony or crime of moral turpitude?
—Please choose an option— Yes No
(Any such plea or conviction must be disclosed even if the case was later expunged or dismissed. Such disclosure will not automatically prevent your membership in our Order, but may be a factor to be considered by the membership.) I understand that the Lodge may perform a criminal background check to verofy the information provided.
9. (a) Have you ever served in the armed forces of the United States of America?
(b) If yes, state the type of discharge and branch of service:
10.(a) Have you ever been proposed for membership in any Elks Lodge?
(b) If yes, Lodge:
11. Have you been a bona fide resident within the jurisdiction of this Lodge immediately preceeding the date of this application?
12. (a) Provide two references other than the Proposer. All must be Members of the Order. (Fill out form on back panel.)
(b) List all places of residence and your occupation for the 5 years preceding the date of this application if different from the address and/or occupation given on reverse side (Fill out form on back panel.)
EXCERPTS FROM LAWS OF THE ORDER
The lodge Dues are per annum and may be paid semi-annually in advance on April 1st of each year, as provided in the By-Laws of the Lodge. An Applicant rejected must wait six months before reapplying for membership. Rejected Applicants shall have their Initiation Fees returned to them by the Lodge.
Should a Candidate fail, without good cause, to appear for Initiation within four months from the date of the Candidate's Initiation Fee will be forfeited.
I understand that this application must be fully completed and accompanied by any application and initiation fees required by the Lodge; and that pro-rata membership dues, assessments and state association dues and fees, for the current year, must be paid at the time of initiation. I further understand that the Benevolent and Protective Order of Elks is a private organization, and that if I do not meet the established requirements and receive membership approval, I will not be granted admission into the Order.
Applicant
Date
