1. Full Name (as you wish it to appear on your certificate):

_____________________________________________________________________

2.Your Mail Address: ___________________________________________________

___________________________________________________

3. Date awarded Knight Of the Order, Third Class (Squire) ____/____/____ (month/day/year)

4. Check One: ______Male _____ Female

5. You must agree to the following to be advanced by our order and receive the rank of Knight Of The Order, Second Class (Officer): "I state that I seek to advance in The International Order of the Knights of Saint Luke for honorable purposes and with a sincere heart. I agree to endeavor to follow the discipline of this rank, to practice courteous and charitable acts in my daily life even beyond what might ordinarily be expected, that I will always seek to do my best for the order, that I will endeavor to act to always reflect well on the order, and that I will respect and show true Christian love and compassion toward all peoples, and especially my fellow members of this order. I further state that I will also seek to always reflect positively on Saint Luke Evangelical Christian Ministries, the sponsoring ministry of this order."

________ I agree to the above. (order cannot be processed unless checked)

Copy and paste this form into an e-mail, fill it out appropriately, and e-mail it to Brother Dave. Use PayPal to send in your payment of $40.00.