Form R-21
APPLICATION FOR RECEPTION OF HOLY ORDERS
Title III, Canon 10.3
DIOCESE OF LONG ISLAND
I was born on ________________________________________
I attended the Day of Discernment on _____________________
I was received as an Episcopalian on _____________________
I hereby intend to exercise my ministry
in the Church and the world in the following manner:
NAME: _________________________________________________
(Print)
SIGNED: ________________________________________________
DATE: _________________________________________________