BROKEN RITES APPLICATION FORM

Please use block capitals

Name ...............................................................…………….................................

Date of Birth .........................

Address ..........................................................................……………….................

...............................................................................................................................

Postcode ........................... Telephone number ...............................................

E-mail address ……………………………..…………………………….....................

Denomination (C of E, URC, Methodist etc.) ...................………….......................

(Anglicans only) Diocese where break up occurred ..............................................

(Anglicans only) Diocese where now living ...........…............................................

Year of marriage/partnership .........…............ Year of separation ………..….........................

Year of divorce ...……........……... Year of spouse/partner’s ordination ........................

Children’s dates of birth ......................................……………….............................

....………………………………………………………………………………...............

How did you hear of Broken Rites? ………………………………………….............

Would you like to meet a Broken Rites Member in your area? YES/NO

May we share your contact details with members in your region? YES/NO

(Anglicans only) Are you in contact with your Bishop’s Visitor? YES/NO

SIGNED .................................................. DATE ............…………........

Annual subscription £15. In case of hardship not less than £2.
Please make cheques payable to Broken Rites and send with the form to The Treasurer: Lucille Trotter, 9 Sir William Turner's Court, Kirkleatham, Redcar, TS10 4QT  or email: treasurer@brokenrites.org

All information on this form will be treated in confidence within Broken Rites.