<p>The Moorish Divine and National Movement Moorish Holy Temple of Science Great Seal Moorish Science Temple of America Ontario Territory, Canaanland Republic</p><p>Nationalization and Name Correction Honourable Membership Form</p><p>I AM ______(Moorish Name)</p><p>I, ______, being first duly affirmed, depose and state:</p><p>(1). My Name at Birth as on Birth Certificate ______</p><p>(2). That I was born on ______, in the Territory of ______,</p><p> in ______Republic State, ______County.</p><p>(3). Federal / Social Identification Number: ______-______-______</p><p>(4). UN # _(no entry)_</p><p>(5). Height ______(6) Weight ______lbs. (7) Eye Color ______(8) Hair Color ______</p><p>(9). That I presently reside; domicile at ______(street address, city, state, postal zone)</p><p>(10). Contact Number: home ______cell ______work ______</p><p>(11). That my current mailing location is at ______. (street address, city, state, postal zone) (if same as above, write “same”)</p><p>(12). That my natural / adoptive (circle one) mother’s full name, including any middle or maiden name is,</p><p>______.</p><p>(13). That my natural / adoptive (circle one) fathers name is ______.</p><p>(14). That I was raised by ______and ______.</p><p>(15). I (check one) have have never been married. If once married, provide name(s) below: ______; ______.</p><p>(16). In Case of Emergency Contact: ______. (name, relatione, phone number)</p><p>(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: </p><p>______</p><p>(19). That my current occupation is ______.</p><p>That my current employer is ______.</p><p>That my current employers address is ______.</p><p>(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. </p><p>______</p><p>______</p><p>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:</p><p>(a) Name ______Date ______</p><p>Jurisdiction ______.</p><p>(b) Name ______Date ______</p><p>Jurisdiction ______. </p><p>(21). That during the past ten years, I have resided (domiciled) in the following locations and length of term.</p><p>(a) Address ______City ______</p><p>State/Province ______Length of Years: From ______To ______</p><p>(b) Address ______City ______</p><p>State/Province ______Length of Years: From ______To ______</p><p>(22). That the Correction of name request is not: Circle all that apply.</p><p>(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: ______.</p><p>(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)</p><p>(24). I (check one) have have not been any previous applications to assume another name.</p><p>(25).This application is not being made with the intent to avoid creditors or criminal prosecution or for other fraudulent purpose. (Initial if agree)</p><p>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.</p><p>This ______day of ______, 20 </p><p>Applicant Autograph: ______</p><p>______Grand Sheik Secretary Kudjo Adwo El Amaury El Bey</p>