"Form of Dispensation for a New Lodge.
Grand Lodge of Free and Accepted Masons of the State of ______________.
To all to whom these present may come, GREETINGS:

"WHEREAS, a petition has been presented to me by Brothers ____________, residing within this jurisdiction, praying, on account of the convenience of their respective dwellings, and for other good reasons, for a Dispensation to empower them to assemble as a legal Lodge, to discharge the duties of Masonry in the several degrees of Entered Apprentice, Fellow Craft, and Master Mason, in a regular and constitutional manner, according to ancient forms of the Fraternity, and the constitution and regulations of this Grand Lodge;

"And, WHEREAS, The said petitioners have been recommended to me as Master Masons in good standing by the Worshipful Master, Wardens and brethren of ___________ Lodge, No. ___, under our jurisdiction; Therefore, I, ____________, Grand Master of the State of ____________, by virtue of the authority in me vested, do hereby grant this my Dispensation, authorizing and empowering our trusty and well-beloved brethren aforesaid, to form and open a new Lodge in the _____ of ______, in county of ___________, and State of __________, to be called ___________ Lodge, and therein to admit and make Entered Apprentices, Fellow Crafts, and Master Masons, in accordance with the ancient usages and customs of the fraternity, obeying in all things the constitution, laws, and edicts of this Grand Lodge, and not otherwise. "And I do hereby appoint our worthy brother, A B, to be the first Master; Brother C D to be the first Senior Warden, and Brother E F to be the first Junior Warden of said new Lodge.

"And it shall be their duty, and they are hereby required to return this Dispensation with a correct transcript of all proceedings had under the authority of the same, together with an attested copy of their by-laws, to our Grand Lodge, at its next annual communication, for examination, and such further action as shall be deemed wise and proper.

"This Dispensation to continue in full force till the annual communications aforesaid, unless sooner revoked by me.
"In testimony whereof, I have hereunto set my hand and seal, this ___ day of ___, A.D. 19__.
_________________________________,
Grand Master."