E-Petition – Mirza Shriners

Home
Calendars
- Mirza Calendar
- Blue Lodge Calendar
Our Organization
Become A Shriner

Home
Calendars
- Mirza Calendar
- Blue Lodge Calendar
Our Organization
Become A Shriner

Mirza Shriners
110 West 5th St
Pittsburg, KS 66762

Public Events
News
- The Mirzan & Blog
Rent Our Facilities
Support

Public Events
News
- The Mirzan & Blog
Rent Our Facilities
Support

Home
Calendars
- Mirza Shrine Calendar
- Blue Lodge Calendar
Our Organization
Become A Shriner
Public Events
News
- The Mirzan & Blog
Rent Our Facilities
Support

Your First Name *

Your Last Name *

Gender *

Your Email Address *

Your Phone Number *0 / 13

Your Age *

Masonic Status

E-Petition For Membership:

Have You Previously Applied For Admission To Any Temple (Center) Of The Order? *

If YES, please respond accordingly. What Temple (Center)?

When Did You Petition For Membership?

Your Date of Birth *

Masonic Lodge (Name, No. and Location): *(If None - Enter NONE)

Profession | Occupation

Are You Retired?

Residential Street Address (or P.O.Box)

City of Residence

State or Province

Zip Code

First Name of Spouse (if any)

Last Name of Spouse (if different than your own)

Top Line Signer (Full Name):

Second Line Signer:

Interests (check all that apply)Leisure Activities & RecreationMusical, Performing & ParadingOccupational | Professional DevelopmentSocial GatheringsSports & AdventureVolunteer ServiceTravel & Driving

Consent *

Yes, I Consent To Submit This E-Application To Mirza Shrine Center And Agree With Mirza Shriner Terms and Conditions.

Please Type Your Name In The Text Box Below. This Qualifies As Your Signature For The Purpose Of The E-Petition

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