OD 1 Exemplification Registration

Select your Assembly *

Select Registration Type *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

KofC Title (if applicable)

Membership Number *

Full name you would like on certificate

Attach copy of Form 4

Form 4 should be complete with all applicable signatures and infromation and described below.

You can fillout the Form 4 by clicking here. Save it to your computer and upload it to this form.

*Spouse name not manditory

Candidate Selection

	Ceremony Only ($70)
	Priest Candidate Ceremony Only ($40)

Priest Candidate fees should be paid for by the sponsoring Assembly

Group Photo

Picture Qty ($18/each)

Current Total:

$0.00

Payment options *

Mail