Membership Application

(Please Print)


Full Name _____________________________________________________________________

Nickname, if any, for rating report (e.g. Bill for William) ________________________________

Street Address _________________________________________________________________

City,State/Country,Zip ___________________________________________________________

Masonic Lodge #, Name, and Jurisdiction ____________________________________________

(Or OES Chapter, etc.)

Other Masonic Affiliations ________________________________________________________


Masonic Honors ________________________________________________________________

Alternate address dates for "snow birds" (can be approx.) _______________________________

Alternate address ___________________________________________________________

City,State/Country,Zip _______________________________________________________

Birth date _____________________ Home phone (optional) _________________________

E-mail address _________________________________________________________________

Chess Strength (USCF rating, if you have one) _______________________________________

If you do not have a rating, circle your chess skill: Beginner Intermediate Advanced

How did you learn about the MPCC? _______________________________________________

Have you ever played chess by mail before? (Circle one) Yes No

Your first year’s dues are payable in advance:

\$20.00 for Regular members (under age 65)

\$10.00 for Senior members (65 or over)

Please make your check payable to MPCC


Please send this form and your check to: Dennis Plymette

371 Holly Hock Circle

Mountville, PA 17554-1252