DLC Registration

First Name	Last Name		Nickname
Address
City	State/Prov		Zip/Postal Code
Phone w/ Area Code	E-mail
Chapter	Jurisdiction
Birthdate	Age		Year in School
Initiation Date	DeMolay Degree Date		T-Shirt Size
Attended DLCbefore?	Completed RD?		Highest LCC Completed
Chapter Offices Held
District, Regional, Jurisdictional Offices Held
Recommending Advisor Name	Advisor Phone		Advisor Email
Total Registration is $310.00. Indicate your payment options below including any scholarship allowance to total $310.00.
Scholarship	Source		Amount $
VISA/MC	Number Exp. Date Month Year Name on card Note: Card transactions will be processed separately. This form does not initiate a transaction.		Amount $
Mailing check	Mail a copy of your confirmation with your check.		Amount $
Pay by check on-site	Bring check to DLC.		Amount $
Comments (Payment arrangements, scholarship requests, questions, airport or other transportation assistance needed, etc.):
Completed by (if other than registrant)		Name	E-mail