Membership application

Apply online below, or download the printable application for the membership you want. Men’s Lodge and Ladies Auxiliary each use a different form—use the PDF that matches your application.

Men’s Lodge — printable application (PDF)
Ladies Auxiliary — printable application (PDF)

Which membership are you interested in?

About you

Printable form for this membership:

Full legal name *

Date of birth *

Phone *

Cell phone

Email *

Street address *

City *

State *

ZIP *

Wedding anniversary

Date joined

Family lineage Potentini ancestry

Potentini ancestry - names of mother, father, husband, widow of, grandmother, grandfather, great grandmother, and great grandfather

Family lineage, grandparents & place of birth, etc.

Applicant's father

Fathers Name:

Born

If deceased, when?

Address

City, state, country

Phone

Applicant's mother

Mothers Name:

Born

If deceased, when?

Address

City, state, country

Phone

Sponsor's name

Review & submit

By submitting, you agree that the lodge may contact you about membership. This form is delivered by email and saved in the lodge's inquiry dashboard.

Your application includes personal information such as your contact details and date of birth. Submit only if you are comfortable sharing this information with Potenza Lodge through its FormBold inquiry service.

I understand that any information or concealment of any of the facts will operate as forfeiture on my part of any benefits to which I might otherwise be entitled. I further understand that in the event of any failure to pay my dues on or before the due date, all benefits here under shall cease according to the By-Laws of the Lodge. * I understand that I must abide by the by-laws of the Ladies Auxiliary and pay dues each year per the by-laws to remain an active member. I am aware that I must attend a meeting at the time that I join the Auxiliary to get sworn into the Auxiliary. *

Applicant's name *

Applicant's signature *

Date *

Ladies Auxiliary only: A $25 application fee is due with your application. Make checks payable to Potenza Ladies Auxiliary. After submitting this form, a lodge auxiliary member will contact you about the application fee.

A $25 application fee is due with your application. Make checks payable to Potenza Lodge. After submitting this form, a lodge board member will contact you about the application fee.

Prefer paper? Download the application that matches your membership: Men’s Lodge, Ladies Auxiliary. Bring or mail it to the lodge. Questions: 303-477-1722.