Request for a Life Membership Certificate Please prepare and send a Life Membership Certificate for this Master Mason (Form 204) Rank Bro W. Bro V.W. Bro. R.W. Bro. M.W. Bro. First Name Last Name Lodge Name Lodge Number Certificate Required by - Date Certificate Requested by - Name Certificate Requested by - email Grand Lodge Officer Requested Y N Special Instructions Ship to - Street Ship to - City Ship to - Province Ship to - Postal Code Send
