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Ramapo Lodge #485 Knights of Pythias
Membership Record
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Louis Schafer, PACDGC

17 Long Valley Drive

Nanuet, NY 10954

(845)425-5883

Ramapo Lodge #485

KNIGHTS OF PYTHIAS

P.O. Box 311

Monsey, NY 10952-0311

Stan Dresher

128 Doxbury Lane

Suffern,NY 10901

(845)369-0656

 

 

PERSONAL MEMBERSHIP RECORD

Name:

 

Other Address

Other Phone

Address:

 

 

 

City/State/Zip:

 

 

 

Phone No:

 

 

 

Occupation:

 

 

 

Employed By:

 

 

 

Citizen Of:

 

Birthday

Anniversary

Place of Birth:

 

 

 

Wife:

 

 

Relationship

Child 1:

 

 

 

Child 2:

 

 

 

Child 3:

 

 

 

 

 

I certify I have reviewed the foregoing information supplied by me in regard to myself and members of my family, that it is true and complete to the best of my knowledge:

Signed : _____________________  Date: __________ Sponsored By: _______________

 

                                    WAIVER OF PRIVILEGE

 

I hereby state that I fully understand my rights and privileges accorded me and the members of my immediate family, by membership in the Association, and being aware of such rights and privileges, hereby state that I do not wish to avail myself, or the immediate members of my family, of any the rights, privileges and benefits of the Association.

Signature  : _____________________  Date: __________

Witnessed : _____________________  Date: __________

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                                    DO NOT FILL IN BELOW

Page

Esquire

Knight

Suspended

Reinstated

Transferred To

Transferred From

 

 

 

 

 

 

 

                                    Voted in by Lodge ________

Print out and mail in to:
Louis Schaffer
17 Long Valley Drive
Nanuet, New York 10954
(845)425-5883