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 1550 O'Connor Drive Toronto, Ontario, Canada M4B 2V3   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.