To The Potentate, Officers and Nobles of MECCA SHRINERS, situated in the Oasis of New York City, Desert of New York:

I, the undersigned, hereby declare that I am a Master Mason in good standing in the Lodge listed below, which is a Lodge recognized by, or in amity with, the Conference of Grand Masters of North America.  Furthermore, I have resided at my current address for not less than 6 months, as required by the bylaws of Shriners International. I hereby make application to become a Noble of the Order, and a member of your temple.

If granted membership, I promise to conform to the articles of incorporation and bylaws of Shriners International and the bylaws and ceremonies of your temple.