Furthermore, I do not now, and I never will hold membership in or allegiance to, anybody claiming to be Masonic that has been declared clandestine by the Supreme Council 33° for the Northern or the Southern Jurisdiction of the United States of America that I have resided within the jurisdiction of your Center, or in unoccupied territory, not less than six months, as required by the Constitution of the International Council, and that I am not under suspension or expulsion in either of the bodies prerequisite to this Order, and respectfully pray that I may be a Noble of the Mystic Shrine, and become a member of your Center.
I furthermore represent that I have never previously applied for said Order, nor have I to my knowledge, been rejected by any other Center. If I be found Worthy, and my request granted, I promise to conform to all the Ceremonies, Engagements, Constitution, Regulations and Edicts of the International Council together with those of your Center.
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