UNITED GRAND LODGE OF ENGLAND

LIST OF MEMBERS OF

LODGE NO.

AT 31 DECEMBER 200..

MEETING AT

PROVINCE/DISTRICT OF

MEETING DATES

MONTH OF INSTALLATION

LODGE SUBSCRIPTION

FULL £

COUNTRY/NON-DINING £

PAYABLE ON

COMPUTER REFERENCE NUMBER

SURNAME

INITIALS

DATE OF BIRTH

DATE OF I /J/ F / RJ / FJ

If in arrears give date upto which the Brother is clear on  the Lodge Books

REMARKS

 To show dates of death, resignation, Cessation (Rule 148), exclusion (Rule 181) and Election to Honorary Membership

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UGLE ANNUAL DUES

TOTAL MADE PAYABLE TO UGLE

SIGNATURE OF  MASTER

TOTAL MEMBERSHIP

SIGNATURE OF SECRETARY