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:

Total Observers:

Participating Councils - New Members Only

General Observations (Include the number of online members transfering to local council and the council's number): *