Applicant Name: _________________________________
KNIGHTS of PYTHIAS
Application for Membership
Knights of Pythias of Rockland County
I respectfully apply for membership in your lodge by
I declare upon honor that I believe in a Supreme Being, that I am not a professional gambler, or unlawfully engaged
in the wholesale or retail sale of intoxicating liquors or narcotics; and that I believe in the maintenance of order and the
upholding of constituted authority in the government in which I live. Moreover, I declare upon honor that I am not a Communist
or Fascist; that I do not advocate nor am I a member of any organization that
advocates the overthrow of the Government of the Country of which I am a Citizen by force or violence or other unlawful means;
and that I do not seek by force or violence to deny to others their rights under the laws of such country.
I was born in the City of _____________________________________
State, province or Country of _________________________________
On the ______ day of ______________________________,
I am a citizen of (name of country) _____________________________
Residence (P.O. Address) ______________________________
Phone No. (___)_______ City /State/ Zip Code __________________________________
Business address ______________________________________
If this application be granted, I promise a full and faithful observance of all the laws that may govern this lodge
and the Order.
The fee of $____45______ accompanies this application.
Written and signed by my own hand this _______________day of _______ 20__
Signature of Applicant
We, the endorsers of the above applicant certify that the applicant posses all of the necessary qualifications for
membership in the order Knights of Pythias.
Signed ____________________________ _________________________________
Endorsers of Applicant