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Jennings McCall Retirement Center
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Oregon Masonic Lodge Members:

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2150 Masonic Way
Forest Grove, OR 97116
(503) 357-3158
(800) 970-9920
Office hours: 8:00 am to 5:00 pm M-F

Use this form to REPORT NAME And/Or ADDRESS CORRECTIONS ONLY
Date of this report: Month Day Year
Lodge Name & Number:
Your Full Name:
Title



Change of Address No. 1
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 2
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 3
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 4
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 5
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 6
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.



Change of Address No. 7
Member ID No:
Full Name:
DOB:
Place Birth:
Address Line 1:
Address Line 2:
(do not use this line unless for 4-line address)
City:
State/Province:
Zip:
Phone No.


I am finished and ready to send this information to the Grand Lodge. Press below to send.

If you have comments or questions about completing this form please call us or e-mail the Grand Secretaries Office

Thank you!

Form 113