This form to be filled out completely by the District Deputy only. Please complete the form and send to, Jim Chambers, 2921 Easton Blvd., Des Moines, IA 50317-3121
Worthy State Ceremonial Chairman:
Permission is requested to confer the Second and Third Degrees of our Order on:
Date At Council# City
Degree to take place at (address)
Time for degree team to meet with host council people
Location for degree team to meet with council people (address)
Arrival time for Candidates
Starting time for 2nd & 3rd degree
A first degree: will will not be offered. Time
Number of anticipated 2nd & 3rd degree Candidates
Other Districts Involved
District Deputy's Signature (please type)
Your E-mail Address
This form must be completely filled out before approval will be granted.