Certificate Application Form
REQUIRED: Please print legibly and remember to sign the document
Indicate your choice with a check mark for the kind of certificate you want: you may choose all three
( ) Religious Ceremonial Certificate for weddings & more... $25 minumum donation + $5 S&H = $30
( ) Religious Cannabis Certificate for rites and prayers... $25 minumum donation + $5 S&H = $30
( ) Gay Union Certificate... $30 minumum donation + $5 S&H
Name: _______________________________________________________________________________________
as it will appear on the certificate(s)
Name: _______________________________________________________________________________________
full legal name
Title: ________________________________________________________________________________________
Date: ________________________________________________________________________________________
that will appear on the certificate(s)
I, Name _____________________________________________________________________________________
have the sincerely held religious belief that I am...
a Title ______________________________________________________________________________________.
I agree to Ma’at (Truth and Justice) and will refrain from doing any harm.
______________________________________________________________________________________________
Signature:
______________________________________________________________________________________________
Mailing Address:
______________________________________________________________________________________________
Phone Number
______________________________________________________________________________________________
E-mail Address:
Make an online donation or place a check, money order or cash and this document in a stamped envelope addressed to:
Pr Ntr Kmt, c/o michaelm, 340 Old Newport Road #7, Newport Beach, CA 92663, U.S.A..
