Prayer Kit 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: ______________________________________________________________________________________
          (Write your name exactly as you want it to appear on the mailed package.)

Date of Birth: ________________________________________________________________________________
          (You must be of legal age in your area (18 in the U.S.)


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


_____________________________________________________________________________________________
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..