The Consistory of the ____________ Protestant Reformed Church hereby certifies that _____________________ and __________________ are (is a) baptized member(s) of the above congregation, and therefore are (is) subject to the instruction and discipline of that church.
At ___________________ request we hereby transfer our brother (sister) to the Protestant Reformed Church of _____________________, commending him (her) (them) to your Christian fellowship and requesting the consistory to take him (her) (them) under their supervision and in all cases to serve him (her) (them) with Christian counsel.
Date of birth: ____________________________.
Date of baptism: ___________________________.
Done in consistory ________________________,
___________________, President
_______________________, Clerk
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To be returned at the earliest possible moment:
The certificate of _________________________ from the ______________ Protestant Reformed Church has been duly received and accepted.
Dated _______________________
___________________, President
_______________________, Clerk
Notice: The above-mentioned shall be considered still a member of the ___________ Protestant Reformed Church until this receipt is returned properly signed.
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The certificate of ___________________________
Sent to ____________________________
Date sent ___________________________
Receipt returned _____________________
(Cf. Acts of Synod, 1945, Arts. 40, 51; Acts of Synod, 1946, Arts. 17, 19.)