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Electoral Roll Form

ELECTORAL ROLL FORM

Church Representation Rules 1(2) (Appendix 1)

Name

You can put any other names you have with your first name.

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number

Not required but might help us stay in touch better.

Mobile Telephone

Not required but might help us stay in touch better.

I DECLARE THAT

1. Baptism declaration

Please select ONLY ONE of the options below

If you are not yet 16 please enter your date of birth below.

*Those who become 16 during the next 12 months may complete the form and become eligible to be entered on the Roll on their sixteenth birthday.

YYYY

2. Church membership declarations

Please select ONLY ONE of the options (a), (b), or (c)

Date of submission

YYYY

Notes

1. The only Churches at present in communion with the Church of England are other Anglican Churches and certain foreign churches. 2.Membership of the electoral roll is open to members in good standing of a Church not in communion with the Church of England which subscribes to the doctrine of the Holy Trinity where those members are also prepared to declare themselves to be members of the Church of England 3. Every six years a new roll is prepared and those on the previous roll are informed so that they can reapply. If you are not resident in the parish but were on the roll as an habitual worshipper for the past six months, you may write "would" before "have habitually attended" on the form and add "but was prevented from doing so because..." and then state the reason. 4. If you have any problems with the form please approach the clergy or lay people responsible for the parish, who will be pleased to help you. 5. In this form "parish" means ecclesiastical parish.

Electoral Roll Form

ST STEPHEN’S CHURCH,

SHEPHERD’S BUSH