Losses in Membership Report

Please provide the following contact information (* = Required Field):

Lodge Name/Number: * *  
Lodge Address:
City:
State:
Zip Code:
Lodge Phone:
Lodge FAX:

Member 1 Information

Name: *  
Reason: *  
Membership #: * (Please use membership roster to obtain membership #.)  

Member 2 Information

Name:
Reason:
Membership #: (Please use membership roster to obtain membership #.)

Member 3 Information

Name:
Reason:
Membership #: (Please use membership roster to obtain membership #.)

Member 4 Information

Name:
Reason:
Membership #: (Please use membership roster to obtain membership #.)

Member 5 Information

Name:
Reason:
Membership #: (Please use membership roster to obtain membership #.)