Membership Application
If you are interested in becoming a member please print the application form below or contact the Lodge at : Emilia Sammartino Lodge #2831,PO Box287, Crabtree,PA 15624 or email to:
Andrea Pomponi at: ziainpa@comcast.net or email to: clentin@comcast.net
TO BE COMPLETED BY LODGE SECRETARY: ALL LINES MUST BE COMPLETED TO BE ENROLLED IN OSIA
I hereby apply for Membership in the____________________________________ Lodge no._______ of the Grand Lodge of Pennsylvania, Order Sons of Italy in America.
Name_____________________________________________________ Address______________________________________________________________
(Please print)
City___________________________________ State __________ Zip_____________ Phone: Home (___)________________ Work (___)___________________
Cell (___)______________________ Fax (___)____________________ Email _______________@___________ Smoker ___ Non-Smoker ___ (applicant)
*** Beneficiary__________________________________ Relationship______________________ (Please print)
Current Age ________ Date of Birth _________________ Place of Birth_________________________Occupation_____________________________
Married ____ Single ____ Widowed ____ Name of: Husband___________________ Gender: Male ______ Female______
Wife______________________
(Maiden Name)
Are you of Italian ancestry? Yes ___ No ___ Name of: Father ________________________ Is your spouse of Italian ancestry? Yes ___ No ___
Mother _____________________
(Maiden Name)
Have you ever been a member of the Order? Yes_____ No_____ Number of Lodge ___________ Is spouse a member? Yes _____ No _____ If yes, Lodge # ________________________
I AGREE THAT NO DEATH BENEFIT SHALL TAKE EFFECT UNTIL INITIAL DUES HAVE BEEN PAID.
***MEMBERSHIP INCULDES A $500.00 INSURANCE POLICY FOR AGES 0 TO 54 AS PART OF MEMBERSHIP PACKAGE***
If accepted as a member, I agree to be bound by the present and future laws of the Supreme Lodge of the Grand Lodge of Pennsylvania, and of the lodge of which I become a member. I believe in the fundamental principle of God and Country, and do not profess any doctrine that aims unlawfully to overthrow the social order or the organized government by force of violence.
I affirm that I know the applicant and believe him/her to be a person of good moral character and qualified to become a member of the Order.
_____________________________ ______________________________ __________________________________ Date ________________
(Print Sponsor Name) (Signature of Financial Secretary) (Signature of Applicant)
(Are you interested in our life insurance program for yourself or any member of your family? Yes ____ No ____
(Would you like someone to call to explain our life insurance program? Yes ____ No ____
(Are you interested in other insurance and annuity programs? Yes ____ No ____
Answer ALL questions. PRINT OR TYPE INFO. Use ink only. Immediately after initiation the lodge financial secretary shall submit the original completed application with the application fee to the Grand Lodge of Pennsylvania. PHOTOCOPIES OF COMPLETED APPLICATION NOT ACCEPTED.
The dues schedule for 2012 is below
The Regular membership dues for the Emilia SammartinoLodge for 2012 will be $15 for 0-11 years( Infant), $25 for 12-17 years, $60 for 18-74 years, Annual dues for 75+ years is $10 for 2012which includes $500 in life insurance for those under the age of 55 at the time of registration. Social Membership dues are $60 per year.
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