§ Certificate of Appointment or Admission of a Minister to a separate Congregation.
§ To the justices of the peace at the general session of the peace to be holden for the county, (riding, city or town, as the case may be), of We, whose names are hereunto subscribed, being respectively substantial and reputable householders, belonging to the separate congregation of dissenting Protestants of the sect or persuasion denominated [Here describe the sect or persuasion of dissenters] duly certified and recorded (or registered) according to law, to be holden at [Here insert the house, chapel, or place, and the parish, town, and county where the congregation assemble] do certify that A. B. of being in holy orders (or pretended holy orders, or pretending to holy orders, as the case shall require) hath been appointed minister of the said separate congregation, and has been admitted and is in the peaceable possession of the place of minister of the same. Given under our hands this day of in the year of our Lord
| Signed and subscribed by the above-named C. D., E. F. G. H., I. K., L. M., and N. O. in the presence of P. 2. of the day above written. | (Signed) |
| C. D. | I. K. |
| E. F. | L. M. |
| G. H | N. O. |