Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1: I declare that (please tick only one box from options A or B) *

1A: I am baptised, am a lay person, and am aged 16 or over

1B: I am baptised, am a lay person, and become 16* on...

2: I declare that (please tick only one box from options A, B, C, D or E) *

2A: I am a member of the Church of England (or of a Church in communion with the Church of England) and am a resident in the parish.

2B: I am a member of the Church of England or of a Church in communion with the Church of England, am not resident in the parish, but have habitually attended public worship in the parish during the preceding six months.

2C: I am a member of the Church of England or of a Church in communion with the Church of England, am not resident in the parish, and would have habitually attended public worship in the parish during the preceding six months but was prevented from doing so because... *

2D: I am a member in good standing of a Church which is not in communion with the Church of England but subscribes to the doctrine of the Holy Trinity, am also a member of the Church of England and have habitually attended public worship in the parish during the preceding six months.

2E: I am a member in good standing of a Church which is not in communion with the Church of England but subscribes to the doctrine of the Holy Trinity, am also a member of the Church of England and would have habitually attended public worship in the parish during the preceding six months but was prevented from doing so because... *

Date *

Select the date you are submitting this form.

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