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To the Most Worshipful Grand Master of the Grand Lodge of Free and accepted Masons of the State of Virginia.

We the undersigned being Master Masons of good Standing, and having the best interest of the Craft at heart are anxious to exert our best endeavors to promote and diffuse the genuine principles of Free Masonry and for the convenience of our respected Dwellings and other good reasons, for our Assurance of forming a New Lodge at Clifton in the County of Fairfax to be named Acacia We therefore respectfully pray For a dispensation empowering us to open and hold a regular Lodge at Clifton and therein to discharge the duties of Ancient York Masonry in a Constitutional Manner according to the forms of the order and the Laws of the Grand Lodge, and to have nominated and do recommend Worshipful Brother John Y. Worthington to be the first Master, Worshipful Brother Geo P Wright to be the First Senior Warden and Brother Thomas Burke to be the first junior Warden of the said Lodge. Should the prayers of the Petitioners be granted we promises a strict conformity to all the regulations of Masonry and the laws, resolutions and edicts of the Grand Lodge.