apply for membership in a Scientology Religious Order and for active participation as a staff member within the Church of Scientology of
_
__________________________________________________________________
(address)
hereinafter referred to as the "Church" for a period of five (5) years / two and one-half (2 1/2) years (circle appropriate period).
Acceptance of my application is based on the following information:
INFORMATION
1. (If a Minor). I have obtained the consent of my parents or guardian to the commitment and participation herein described, for the Church of Scientology, which consent is indicated beneath my signature.
2. I have never been convicted of the commission of any criminal felony under the laws of any jurisdiction. 3. I have no institutional history of psychosis.
4. I have no electric, insulin or other shock or psychiatric brain operation history.
5. I am not an active drug pusher.
6. I have never sued the Church, or any Scientology organization or made complaint to any governmental authority with respect to the Church, any member of the Church, or any
Scientology organization.
7. I am not a blown staff member or blown Sea Organization member. That is, I have never, without authorization in accordance with Church Policies, departed from any staff position within any
Scientology organization or broken my vow of service as a member of the Sea Organization, a religious order of the Church of Scientology.
OR
I have in the past blown, as described above, but have since recanted and been given forgiveness and accepted back into the Scientology religion after having made proper restitution.
8. I am not related to or connected with any intelligence agency, either by past history or immediate familial connection.
9. I do NOT have a parent or a guardian who is an antagonist of the Scientology religion, or of any organization devoted to Scientology applied religious philosophy.
10. I am not seeking a staff position to obtain material for dissemination to the public via press, radio, television, motion picture or other media. I do not seek to obtain data for any other organization or to disrupt the Church organization.
11. I do not have personal debts of a magnitude such that efforts to satisfy them would immediately disrupt or cause me to pull back from my commitment to the Church.
1Z. I do not have any mental institutional history, by which is meant voluntary or involuntary stay in a mental institution and knowingly or unknowingly receiving treatment therein.
13. I have no prior service in a high security section of the government or armed forces.
14. My spouse has no objections to my working for the Church.
15. I am not currently on drugs.
16. I have seen the film "Orientation" and I am now informed and aware that Scientology is a religion, its teachings are religious and its claims are religious in nature. I further understand that if I desire to participate in Scientology services, I do so being fully aware that these are religious services and that I am participating in them under the ecclesiastical principles of the Scientology religion. 17. I attest that I have been given and read Scientology Policy Directive 13 March 1996,
Statements by Staff Members, and Scientology Policy Directive t 3 March 1996, Return of
Donations.
(Exception to any of the above can be made only after an applicant has petitioned a Senior
Officer of the Church and received unconditional acceptance. Such written approval must be presented to HCO before signing the Declaration.)
I UNDERSTANDAND AGREETHAT BY THIS DECLARATION I AM DECLARING
A RELIGIOUSCOMMITMENT TO SPIRITUALAWARENESS,TO THE SCIENTOLOGYRELIGION AND
TO CREATEA BETTERWORLD, IN ACCORDANCE WITH THIS DECLARATION.
PLEASEINITIAL __
I FURTHERUNDERSTANDTHAT ALL CHURCH STAFFMEMBERS INCLUDING MYSELF,ARE
MEMBERS OF A RELIGIOUSORDER;THAT THEY SERVEPURSUANTTO THEIRRELIGIOUS
OBLIGATIONS AND NOT IN
