THE RIGHT WORSHIPFUL GRAND LODGE OF THE MOST ANCIENT AND HONORABLE
FRATERNITY OF FREE AND ACCEPTED MASONS OF PENNSYLVANIA
Masonic Temple, One North Broad Street, Philadelphia, PA 19107-2598
The Lewis Jewel Application Form
I, ______________________________________, would like to apply for a Lewis Jewel.
The Lewis Jewel may be worn by a Mason, if, at the time of his Initiation, his father was a Mason in good standing. The initiate of a deceased father - in good standing at the time of his death - would also qualify.
The following information is provided for the Lodge Secretary and the engraver (Please print clearly):
Father's name: First, M.I., Last: ______________________________________
Date of Father's Initiation (1st Degree): ______________________________________
Lodge of Father's Initiation: ______________________________________
  
Son's Name: First, M.I., Last: ______________________________________
Date of Son's Initiation (1st Degree): ______________________________________
Name of Son's Lodge: ______________________________________
Location of Lodge: ______________________________________
Name of Secretary of Lodge (Please print): ______________________________________
Address of Secretary:(Street)______________________________________
(City, State)______________________________________
(Zip Code)______________________________________
I have investigated and verify the names and dates as stated above are correct. I also verify that the father was a Mason in good standing at the time of the son's Initiation.
Attest:
Signature of Secretary: ______________________________________
Forward Application and check for $58.00 USD to:
Dominion Regalia Ltd
4 Overlea Boulevard
Toronto, Ontario, Canada
M4H 1A4
 
For information or order status call: Keith MacDonald at 1-866-423-4086
Instructions to Lodge Secretary: If father was not initiated in your Lodge, please contact the Grand Secretary's Office at (215) 988-1901 for verification of date and status.