IF THERE ARE ANY PROBLEMS WITH THIS FORM, PLEASE CONTACT JIM MASLACH AT 440-785-9838 OR VIA EMAIL AT kofcjkm@gmail.com.

Report Date:

Jurisdiction: *

District Number: *

Degree Date: * +

Host Council Number: *

Submitted By:
*

Title: *

Membership #:
*

Email Address: *

Select Diocese: *

Only submit one report per Degree.
DO NOT report multiple Degrees on a single form.

Exemplification: *

Exemplification of Charity, Unity, and Fraternity

Admission/1st Degree

Formation/2nd Degree

Knighthood/3rd Degree

Location:

Church

Council Chamber

Other

Honoree (If Designated):

Total Number of Candidates:

Length of Exemplification:

Candidate Details (for Exemplification of Charity, Unity and Fraternity only)

# New Members:

# Priests:

# Online Members:

# Advancing Members:

# Observers:

Participating Councils - New Members Only
In the space provided below, please enter the council number and the number of new members.
DO NOT include Online or Advancing Candidates.

	Council #	# New Mbrs
1	Council #	# New Mbrs
2	Council #	# New Mbrs
3	Council #	# New Mbrs

	Council #	# New Mbrs
4	Council #	# New Mbrs
5	Council #	# New Mbrs
6	Council #	# New Mbrs

	Council #	# New Mbrs
7	Council #	# New Mbrs
8	Council #	# New Mbrs
9	Council #	# New Mbrs

	Council #	# New Mbrs
10	Council #	# New Mbrs
11	Council #	# New Mbrs
12	Council #	# New Mbrs

General Observations about Exemplification.
List Last Name and Council Number for All Candidates Above (New, Priest, Online, and Advancing) *