LODGE ................................  

REGISTER OF MEMBERS

Name (Surname or Name  by which known)

Christian Names or other Names in full

Place of Abode (Full Address)

Profession / Occupation / Trade

Employer and Business Address

Date of Birth / Age

Initiated

Passed

Raised

In Lodge No.

Date

In Lodge No.

Date

In Lodge No.

Date

Joined

Joined

Membership ceased

Lodge No.

Date

Lodge No.

Date

Lodge No.

Date

REMARKS 

Offices Held

Lodge

Office

Year

Lodge

Office

Year

Grand / District Grand Lodge *

Office

Year

Date Registration Form Received: ..........................................  Date Registration Form Sent to DGL ....................................

Grand Lodge Certificate Number...........................................  Date........................ Date presented ..........................

In the case of a Joining Member: Constitution ................................... (Grand Lodge Certificate No. and Date to be noted above)

In the Case of a Rejoining Member : Previous Register No. .................................. and Date of cessation .........................

*Ranks in sister constitution may also be noted here

  Register Number