I Care About...

"I Am An Elk"

ELKS MEMBERSHIP APPLICATION

First Name:		Last Name:
Home Address:		City, State & Zip:
Personal Telephone:		Personal E-Mail:
Occupation:		Business Name:
Business Address:		City, State & Zip
Business Telephone:		Business E-Mail:

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City of Birth:		County:
State:		Date Of Birth:

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Do you believe in God and are you willing to attest to that belief?

Yes

No

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Are you a Citizen of the United States of America?

Yes

No

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If foreign born, when and where were your final naturalization papers issued:

Month:

Day:

Year:

Location:

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Are you willing to assume an obligation that:
(a) Will not conflict with your duties to yourself, your family or your religious or political opinions, and that,
(b) Will bind you to uphold the Constitution and laws of the United States of America?

Yes

No

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Are you now a member of or directly or indirectly participating in the activities of any group or organization, or supporting or adhering to beliefs or tenets advocating the overthrow of the Government of the United States or any of its political subdivisions by force or violence?

Yes

No

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Have you ever pled guilty or no contest to, or been convicted of, a felony or crime of moral turpitude?

Yes

No

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Have you ever served in the armed forces of the United States?

Yes

No

If yes:

Type of discarge:

Branch of Service:

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Have you ever been proposed for membership in any Elks Lodge?

Yes

No

If Yes:

Lodge:

Date:

Result:

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Have you been a bona fide resident within the jurisdiction of this Lodge immediately preceding the date of this application?

Yes

No