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Petition for Initiation
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To the Officers and Members of Dallas Lodge of Perfection, Dallas Chapter of Rose Croix, Dallas Council of Kadosh and Dallas Consistory of the Ancient and Accepted Scottish Rite of Freemasonry, located at Dallas, Texas: I, the undersigned, respectfully petition to receive the Scottish Rite Degrees 4° - 32°, and hereby certify to the following:

If so required, have you passed a Blue Lodge proficiency examination in the Master Masons Degree? Yes  No

Do you promise to bear true Faith and Allegiance to the Supreme Council, 33° S.J.U.S.A.? Yes  No

Do you approve of the “Inculcation of Patriotism and Respect for Law and Order?” “The entire separation of Church and State?” “Opposition to every attempt to appropriate public monies – Federal, State or Local – directly or indirectly, for the support of sectarian or private institutions? Yes  No

Have you ever held or expressed opinions contrary to the foregoing or been affiliated with any organization which has? Yes  No

I am a Master Mason in Good Standing in Lodge, Number
located at under the jurisdiction of the Grand Lodge of .
Year raised .

Full Name:
 First   Middle    Last
Mailing Address: 

  Zip: -
Home Phone: 
Cell Phone: 
Work Phone: 
Fax Number: 
Email Address: 
Date of Birth: 
/ /    Birth Place:
Spouse Name: 
   Spouse DOB /  MM/DD Only


 (Please be specific) 
Recommended By: 
   S/R ID Number:
 Non-refundable down payment of $100.00 will be collected on the next screen via online payment. To pay the full amount, change the amount field in the "other" section from $100 to $500.