I, the undersigned (a) , of , in the county of , do hereby, under and by virtue of the Places of Worship Registration Act 1855 certify that a certain building known by the name of , situated at , in the county of , within the superintendent registrar’s district of , [was used (b) as a place of meeting for religious worship before the 30th day of June 1852 and] is intended to be used as heretofore (c) and will accordingly be forthwith used as a place of meeting for religious worship by a congregation or assembly of persons calling themselves (d)

and I request that this certificate may be recorded in the General Register Office, pursuant to the said Act. Dated this day of , 185 .

(Signature of the party certifying.)

(e)

of the place of meeting above described.

Directions for filling up this schedule.

(a) Here insert the name, residence, and county in which it is situate, and the rank or profession, of the party certifying.

(b) If the place was not so used before 30th June 1852, expunge this and the following line.

(c) If the building have not been previously used as a place of worship erase the words “as heretofore.”

(d) Here insert “Protestant Dissenters,” “Independents,” “Particular Baptists,” “Wesleyan Methodists,” “Roman Catholics,” “Jews,” or other religious denomination of, or religious appellation adopted by, the persons on whose behalf the building is certified; but if those persons decline to describe themselves by any distinctive appellation, erase the words “calling themselves,” and insert “who object to be designated by any distinctive religious appellation.”

(e) Insert on this line, immediately under the signature, the word “minister,” “proprietor,” “a trustee,” “occupier,” “an attendant,” or such other words as will clearly show the connexion subsisting between the persons certifying and the place of meeting.