I do hereby certify that all of the information contained in the attached Enrollment Application and Questionnaire is accurate and complete to the best of my knowledge. I understand that if any of the information is later determined to be false, my membership in the CanonLawyer Clergy Assistance Plan will be subject to termination. 


  _______________________________ (sign)

Name (print): _____________________________________

Date _____________________



Print, sign and return this form along with the Application, the Questionnaire or the Fillable Form and the Application Fee to  CanonLawyer, Inc., 5 Route 94, Suite A, Vernon, NJ 07462.

                                                        Fillable Form         Credit Card Payment