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SECRETARY/RECORDER PORTAL
Documents and Forms
Application for Longevity Certificate
Application for Longevity Certificate
companion
2025-06-12T17:58:17+00:00
Application for Longevity Certificate
Today's Date
(Required)
MM slash DD slash YYYY
Longevity Level
(Required)
25 Years
40 Years
50 Years
55+ Years
Companion's Full Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Companion's Place of Birth
(Required)
Companion's Date of Birth
(Required)
MM slash DD slash YYYY
Place and Date Degrees Conferred
Chapter where Companion was exalted
(Required)
Date of Exaltation
(Required)
MM slash DD slash YYYY
Council where Companion was greeted
(Required)
Date Greeted
(Required)
MM slash DD slash YYYY
Commandery where the Companion was knighted
(Required)
Date Knighted
(Required)
MM slash DD slash YYYY
Was the Companion ever suspended for NPD?
(Required)
Yes
No
If Yes, when?
MM slash DD slash YYYY
Date reinstated
MM slash DD slash YYYY
Secretary Name (Your Name)
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Certification
(Required)
I certify that the information provided above is accurate to the best of my ability.
Certificate
Select Certificate(s)
(Required)
Chapter
Council
Commandery
Select All
Convenience Fee
(Required)
Price:
$0.00
Total
Credit Card
(Required)
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