PrNtrKmt Donation Center
ID Card Application Form
Print: On PC Keyboard, Hold Control Button & Press P, as in Print / On Mac, It's Command P
REQUIRED: Please print legibly and remember to sign the document


Name: _____________________________________________________________________________________
          (as it will appear on the ID card and certificate)

Date of Birth: _______________________________________________________________________________


I, (Name) ____________________________________________________________________________________
have a sincerely held religious belief that cannabis is essential for my religious practice of Neter Sentra.


_____________________________________________________________________________________________
Signature:

Photo: You must provide four color photographs of passport size or larger (not to exceed 8x10). Passport size photos are best (and widely available). None of the submitted photos will ever be returned.


_____________________________________________________________________________________________
Mailing Address:

_____________________________________________________________________________________________
Phone Number

_____________________________________________________________________________________________
E-mail Address:

Now make your 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, 1024 Bayside Dr. #420, Newport Beach, CA 92660-7462, U.S.A..

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