Electoral Roll Application Form

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Full Name: *

Address: *

Post code: *

1A. I declare that I am baptised, am a lay person and am aged over 16. *

Yes

Required

1B. If I am not yet 16, I declare that I will become 16 in the next 12 months on the following date:

YYYY

Please tick ONE of the following: *

2A. I am a member of the Church of England (or 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 a church in communion with the Church of England), and, not being a resident in the parish, I have habitually attended public worship in the parish during the period of six months prior to enrolment.

2C. I am a member in good standing of a Church (not in communion with the Church of England) which subscribes to the doctrine of the Holy Trinity and also declare myself to be a member of the Church of England and I have habitually attended public worship in the parish during the period of six months prior to enrolment.

Required

(Please refer to notes 1-5 below for any clarifications. A map showing the parish boundaries for the St Luke Oseney Crescent parish is given below).

I declare that the above answers are true and I apply for inclusion on the Church Electoral Roll of the Parish.

Signed: *

Today's date: *

YYYY

Data Privacy: *

I am happy for St Luke's to hold these details on record, for my full name only to appear on the public Electoral Roll list, and with the other points listed below in notes 6-10.

Required

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