Electoral Roll Form  

There are various options that need to be ticked on this form. Please ensure that you read the form carefully and only tick what is necessary otherwise your application may not be valid.
 

Full Name:

Address:
Town:
County:
Postcode:
Country:

Telephone/Mobile:
Email:

Use of email addresses and other personal data
 

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 (fill in below)  *Those who become 16 in the next twelve months may complete the form and become eligible to be entered on the roll on their sixteenth birthday.

2:  I declare that (please tick only one box from options A, B or C)   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. OR 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]                   or               [and would have habitually attended public worship in the parish during the preceding six months but was prevented from doing so because  OR

2C*       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]                 or              [and would have habitually attended public worship in the parish during the preceding six months but was prevented from doing so because [and have habitually attended public worship in the parish during the preceding six months]

  

*If you tick 2B or 2C in circumstances where a new Roll is being prepared, you must select either the first set of words in square brackets or the second set. If you delete the first set, you must complete the second set by filling in the space at the end. see Note 3 on previous page for further information.
 
I declare that the above answers are true and I apply for inclusion on the church electoral roll of the parish.
 
Signed*:    Date: