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To: Dutchess Lodge No. 860 Knights of Pythias, of New York.

I respectfully apply for membership in your lodge by (pick one)

INITIATION_____ TRANSFER_____ REINSTATEMENT_____

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 declared upon honor that I am not a Communist or Fascist; that I do not advocate nor am I a member of any orgaization that advocates the overthrow of the Government of the country in which this Order has a legal existence, by force or violence or other unlawful means; and, that I do not seek by force or violence to deny to other persons their right under the laws of such country.

Name__________________________________________________________

I was born in the City of __________________________________________

State, Province or Country of______________________________________

On the____________________________ day of________________, 19____

Address________________________________________________________

City____________________________________ State_____ Zip___________

Telephone (Incl. Area Code)________________EmailAddress___________________________

Occupation________________________Employed by___________________________________

If this application be granted, I promises a full and faithful observance of all the laws
that may govern this lodge and the Order.

The fee of $45.00_____________________________ accompanies this application.

Signed________________________________________________Date__________________