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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
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PERSONAL MEMBERSHIP RECORD
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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
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Voted in by Lodge ________
