Petition for Affiliation or Dual Membership
To the Worshipful Master, Wardens and Brethren of:
Bunting Charity Lodge Number 727, F. & A. M.
Date: .

The undersigned, having been raised to the Sublime Degree of Master Mason in a regularly recognized Lodge of Free and Accepted Masons, makes application to the above named Lodge for affiliation and upon his honor has answered the following questions truthfully:
1. What is your full name? .
2. Where were you born? .
3. What was the month, day and year of your birth? .
4. Where do you reside, stating Borough if within the City of New York? .
5. What is your business occupation and where is it conducted? .
6. Are you at the present time regularly demitted from a Masonic Lodge? .
6a. If so, state the name, number and address of such Lodge .
7. Are you at the present time a member of any Masonic Lodges? .
7a. If so, state the name, number and address of such Lodge .
8. If you should be received into membership in this Lodge, is it your intent to retain your membership in any other Lodge named ... in your answer to question No. 7? .
9. At the present time are you a member of more than one Lodge? .
10. Have you ever presented an application for affiliation with another Masonic Lodge, either in this State or elsewhere, which has ... not been acted on? .
11. Have you ever been rejected, upon your application for affiliation by a Masonic Lodge, either in this State or elsewhere? If so, when and by what Lodge? .
Signature of Petitioner:  
Presented by Brother:  Signature of Proposer: 

of the above Lodge, who hereby certifies that he is well acquainted with the petitioner, that he has read the answers to the questions contained in the petition and believes them to be true and that the petitioner is of good character and comes under the tongue of good report.

REFERENCES
Name:  Address:  Phone Number: 
Name:  Address:  Phone Number: 
Name:  Address:  Phone Number: 
Note: This petition MUST be filled out by the petitioner in his own handwriting. Submit with a $50.00 check, payable to "Bunting Charity Lodge No. 727"