Records Questionnaire

Please take a minute to complete this questionnaire so that we can retain your current information as well as updating information on your Masonic Life. All information will be put into both the Daniel Webster Lodge database and the Grand Lodge (MORI) database.

None of this is mandatory, it is just a way for use to keep up-to-date with your membership. If you have any questions, concerns or other information please contact
the Lodge Secretary:

Wor. Steve Swinhart
e-Mail: secretary@danielwebsterlodge.org
Phone: 781.826.5384

Thank you.

Masonic Title: *
Name: * First: Middle: Last:
Email: *
Home Phone: Cell Phone:
Address 1: *
Address 2: * (P.O. Box, Apt. #, etc.)
City: *
State: * Zip: *
How would you like to receive your Monthly Communications and Notices? (Required)
 e-Mail US Mail
Date of Birth: *
Birthplace: *
City: State:
Foreign Birthplace: City, Country:
Spouse's Preferred Name: (First Last)
Spouse's Date of Birth: Month Day
Spouse Living?
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Masonic Sponsor’s Name: (Proposed by)
Masonic Mentor’s Name: (Proposed by)
Do you have a Masonic Service request in your will?
Do you wish to have a Masonic Service performed?
Masonic Awards received:
 25-Year Anniversary Pin 50-Year Anniversary Pin 60-Year Anniversary Pin
 65-Year Anniversary Pin 70-Year Anniversary Pin 75-Year Anniversary Pin
 80-Year Anniversary Pin 50-Year Past Master Certificate 50-Year Past DDGM Certificate
 Henry Price Medal Joseph Warren Medal Meritorious Service Certificate
 Veterans Medal Lewis Jewel Masonic Rookie Award
 Master Builder's Award Other N/A (not applicable)
Masonic Education received:
 Master's Path Masonic Leadership Institution Ambassador Training
 Lodge of Instruction-1st Class Lodge of Instruction-2nd Class Lodge of Instruction-3rd Class
 Lodge of Instruction-4th Class LOI-Instructor Training Other N/A (not applicable)
Masonic Offices Held:
 Grand Master Deputy Grand Master Any Grand Lodge
 District Deputy Grand Master District Deputy Grand Secretary District Deputy Grand Marshal
 District Awareness District Service Lodge of Instruction Other
 Worshipful Master Senior Warden Junior Warden
 Treasurer Secretary Chaplain
 Marshal Senior Deacon Junior Deacon
 Senior Steward Junior Steward Organist

Other Masonic/Non-Masonic Affiliations:
 Arabic Order Nobles of the Mystic Shrine
Scottish Rite:
 Lodge of Perfection Princes of Jerusalem Chapter of Rose Croix Consistory
York Rite:
 Royal Arch Chapter Council Commandery
Other Bodies:
 Order of the Eastern Star Daughters of the Nile Other
 Rainbow Assembly DeMolay Boy Scouts
Other:
Lodge Affiliations: (Other Lodge Memberships)

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Military Service:
Date Entered:
Date Ended:
Branch:
 Army Navy Air Force Marines Coast Guard National Guard Other
Conflicts:
 World War I (1914-1918) World War II (1941-1945)
 Korean Conflict (1950-1953) Vietnam War (1955-1975)
 Gulf War (1990-1991) Afghanistan (2001- )
 Iraq War (2003-2010) Other
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