Mary Alice’s Majority Association Registration Form

Name: _______________________________________________________________
               First   Last   (Maiden)

Address: _____________________________________________________________

              ____________________________________________________________
               City                                 State                                              Zip Code

Phone: ______________________________________________________________

Email: ______________________________________________________________

Birthday: MM/DD _______________  Initiation Anniversary: MM/DD____________

Assembly of Majority/Jurisdiction: _________________________________________

Assembly of Current Affiliation: ___________________________________________

Grand Cross: Yes _____ No _____

If you are not currently affiliated with an Assembly in Illinois, would you like to be paired
with an Assembly? Yes ____ No ____ N/A ____

If you are unable to be active with a local Assembly, would you like to be sent information
about fundraising for your local Assembly or the Assembly of your choice?
Yes ___ No ____ N/A ____

If yes, please list your choice of Assembly/Assemblies___________________________

Please see the attached M.A.M.A. questionnaire.

Signature of Applicant___________________________________________________

Referred by: __________________________________________________________

Dues of $20.00      (Checks payable to:  M.A.M.A.)

Received by: _______________________  Date Received: _____________
Please mail your dues to:
 Teri Gestautas, Vice President
 7420 S. Banks
 Justice, Illinois  60458