SELF-DEDICANT FORM – ECCLESIA LUCIS ET UMBRAE

Legal Name *

First

Last

Preferred Name (if different)

Email *

Please enter your email, so we can follow up with you.

Phone

Date / Time of Birth *

Date

Time

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date / Time You Performed the Self-Dedication Rite *

Date

Time

Picture of your Cord *

Click or drag a file to this area to upload.

Upload an image of the cord you created during your Self-Dedication Rite. PNG or JPG only, no larger than 64MB.

Member of any other Church or Esoteric Body? *

Facebook Username (if different from your name listed above)

Please List all Church and/or Esoteric Bodies to which you belong, including degree/title/status

ANY COMMENTS OR QUESTIONS?

Captcha *

=