Most Worshipful Prince Hall Grand Lodge F.&A.M

of the State of New Mexico Inc. 525 San Pedro Drive NE

Albuquerque, New Mexico 87108-1859

505-268-5823 FAX 505-254-7638

Request For Dispensation

Request for dispensation will be submitted to the M.W. Prince Hall Grand Lodge fifteen (15) days in advance of the event. Request not submitted fifteen days in advance will have a $10.00 late filing fee imposed.

Request a dispensation be granted to_____________________________Lodge

No.______ for the purpose of________________________________________

on____________________, 20_____in the city of________________________,

New Mexico. Enclosed is a check in the amount of $5.00, payable to Grand Lodge of

New Mexico.

Fraternally,

_______________________

Worshipful Master