To the N.G.V.G. Officers and Brothers of the Loyal.........Lodge

No..............A.I.O.O.F. Of New Zealand.

Brothers,—Herewith I present my Card of Withdrawal from...............Lodge, No............of.................and respectfully ask to be admitted a member of your Lodge, by deposit of the same; (if an Ancient Odd-Fellow, as an Ancient Odd-Fellow).

My residence is................; my age............. years; my occupation is..............; born in.................