To the Potentate, Officers and Nobles of Naja Shriners, Situated in the Oasis of Rapid City, Desert of South Dakota:

I, the undersigned, hereby declare that I am a Master Mason in good standing at a Lodge which is recognized or in amity with the Conference of Grand Masters of North America and the South Dakota Grand Lodge. Furthermore, I have resided at my current address for not less than 6 months, as required by the Bylaws of Shriners International. I respectfully pray that I may be made a Noble of the Mystic Shrine, and become a member of Naja Shriners.

If I be found worthy, and my request granted, I promise to conform to the Articles of Incorporation and Bylaws of Shriners International, and the Bylaws and Ceremonies of Naja Shriners.