To the Grand Lodge of Nebraska:

Application is hereby made for a Membership Award for Brother

Complete all sections that apply

1)	First Name:  Middle Initial:  Last Name:
2)	Expected Date of Presentation
3)	Born
4)	Initiated
5)	Passed
6)	Raised
7)	Proficient
8)	Degrees in		Lodge No.
	Jurisdiction of
9)	Suspensions
10)	50 Year Pin Awarded
11)	60 Year Pin Awarded
12)	Brother's current address:
13)	Is this for a   50 Year Pin60 Year Pin70 Year Pin

Please arrange for presentation by another Grand Jurisdiction of
Nebraska Lodge		YesNo
It is hereby certified that this Brother is a member in good standing of Lodge No.

Fraternally,   Secretary

Secretary Email: