The Moorish Divine and National Movement

The Moorish Divine and National Movement Moorish Holy Temple of Science Great Seal Moorish Science Temple of America Ontario Territory, Canaanland Republic

Nationalization and Name Correction Honourable Membership Form

I AM ______(Moorish Name)

I, ______, being first duly affirmed, depose and state:

(1). My Name at Birth as on Birth Certificate ______

(2). That I was born on ______, in the Territory of ______,

in ______Republic State, ______County.

(3). Federal / Social Identification Number: ______-______-______

(4). UN # _(no entry)_

(5). Height ______(6) Weight ______lbs. (7) Eye Color ______(8) Hair Color ______

(9). That I presently reside; domicile at ______(street address, city, state, postal zone)

(10). Contact Number: home ______cell ______work ______

(11). That my current mailing location is at ______. (street address, city, state, postal zone) (if same as above, write “same”)

(12). That my natural / adoptive (circle one) mother’s full name, including any middle or maiden name is,

______.

(13). That my natural / adoptive (circle one) fathers name is ______.

(14). That I was raised by ______and ______.

(15). I (check one) have have never been married. If once married, provide name(s) below: ______; ______.

(16). In Case of Emergency Contact: ______. (name, relatione, phone number)

(17). I have no unsatisfied judgments of record, or suits pending against me, except: ______(18). I have never been “convicted” of a crime (be it colorable or not), and have no “criminal charges” (with or without trial) pending against me, except:

______

(19). That my current occupation is ______.

That my current employer is ______.

That my current employers address is ______.

(continued on page 2) (20). That my Special Skill(s) / Trade(s) / Interest: ______My Affiliations w/ Temples / Nations / Organizations, in which I were a member of or initiated into degree or rank, or were elected; appointed into office are : List Organization, Rank and Year.

______

That during the past ten years, I have used or have been addressed by the following names in the jurisdiction (s) and on the dates listed below:

(a) Name ______Date ______

Jurisdiction ______.

(b) Name ______Date ______

Jurisdiction ______.

(21). That during the past ten years, I have resided (domiciled) in the following locations and length of term.

(a) Address ______City ______

State/Province ______Length of Years: From ______To ______

(b) Address ______City ______

State/Province ______Length of Years: From ______To ______

(22). That the Correction of name request is not: Circle all that apply.

(a) For any fraudulent or wrongful purpose. (b) Detrimental to the rights or interests of any other person(s). (c) Prohibited by or violative of any judicial or administrative adjudication. (d) Other: Please specify: ______.

(23). That I understand that it is a violation of Common Law to have a willful ill intent in the purpose of changing my name. (Initial if agree)

(24). I (check one) have have not been any previous applications to assume another name.

(25).This application is not being made with the intent to avoid creditors or criminal prosecution or for other fraudulent purpose. (Initial if agree)

I, being “In Full Life” duly Affirmed, do hereby Proclaim , my allegiance to the Living Moorish Nation of the Great Seal Moorish Science Temple of America Temple #10, the Logos Circle Seven, The Organic United States Republic Constitution, The Divine Constitution and By-Laws. I Proclaim and Declare competently, voluntarily, knowingly, intentionally and with full recognition of my Lawful responsibility to the Divine Constitution and By-Laws, also the High Standards of Moorish Science and De jure Law.

This ______day of ______, 20

Applicant Autograph: ______

______Grand Sheik Secretary Kudjo Adwo El Amaury El Bey