CALIFORNIA GRAND ASSEMBLY
MEMBERSHIP ORDER FORM
New Initiate Name

Date Initiated		 Name of Girl or Adult bringing in new member and receiving award* CA Top Bar
$3.00		 R
$1.50		 A
$1.50		 I
1.50		 N
$1.50		 B
$1.50		 O
$1.50		 W
$1.50		 POG
n/c
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Make checks payable to : GRAND ASSEMBLY
(Remember, two signatures required on assembly checks!)

*Please Note
Only one girl OR one adult may receive award per initiate
Amount of Order $_______.____ Assembly :
Shipping $______2.50__ Mother Advisor :
Total Enclosed $_______.____ MA Address
 :
:
. .
. . MA Phone # :
. . MA Email :

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Fill it out and mail to Mrs. Ellen Griffin, PMA at 13046 Spring Lake Street, Redding, CA 96003
Phone: 530-275-3636 (evenings)       Email: EllenG1284@aol.com

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