In applying for membership in the above named Church, I confirm my belief in the Religion of Modern Spiritualism and the acceptance of its Principles. I further confirm that I am familiar with the Religion, Philosophy and Science of Spiritualism and that I have received satisfactory evidence of the continuity of life through the demonstration of mediumship.

Name: _________________________________________________________________________

Address: _______________________________________________________________________

City: __________________State: ________ Zip:________Phone: ________________________

Email Address: _________________________________________________________________

Birth Day: ________________________Place of Birth: _________________________________

Name of Spouse (if married) _______________________________________________________

Business, Profession or Trade: _____________________________________________________

Business Address: __________________________________ Phone: ______________________

If applicant is a member of another denominational Church, evidence of withdrawal of membership should accompany this application. If application is from another Spiritualist Church, a demit is necessary.

Signature of Applicant: _________________________________________

TO BE COMPLETED BY THE PASTOR AND CHURCH SECRETARY

Affirmation of Faith _____________________________________________________________

Letter of transfer or demit (received from) __________________________________________

Recommended by _______________________________________________________________

Date when approved by Church Board ______________________________________________

Date of Reception (Hand of Fellowship) _____________________________________________

Pastor ______________________________ Secretary _________________________________