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305 - 478 Bernard St
Kelowna, BC V1Y 6N7
[email protected]
Phone: 250 712-7597
Fax: 250 712-7598
"MARRIAGE ACT"
Notification of Changes Affecting Religious Representative
To the Registrar General of the Vital Statistics Agency, Victoria, B.C.
Kindly note the following changes regarding the Religious Representative whose particulars are shown hereunder:
Full Name of Religious Representative
Given names
Mailing
Address and Telephone Number
of Religious Representative
Surname
Street Address
Telephone Number
City
Province or State
Religious Body or Denomination
Postal Code
Certificate Number
REGISTRATION TO BE CHANGED AS INDICATED BELOW
(choose one of the following )
1. Change of residence within this present jurisdiction:
New Address
Street Address
City
Province
Postal Code
Telephone Number
2. Transfer to another jurisdiction, Church or Parish within the denomination or religious body:
Name of Parish, Church, Temple, Synagogue
New Title
New Mailing Address and Telephone
Number of Religious Representative
Street Address
Telephone Number
City
Province or State
Postal Code
3. To retain registration upon retirement, effective
4. To cancel registration due to:
Dated at
retirement,
death, or
this
City/Town
State reason
Day
day of
,
Month
Year
Name of Governing Authority
Signature of Governing Authority
Official Title and Extent of Jurisdiction
Mailing Address and Telephone Number
of Religious Body
Street Address
Telephone Number
City
Province or State
Postal Code
NOTE - Where the change reported involves cancellation, the Religious Representative certificate of registration, issued prior to May 9, 2003, MUST be returned with this notice.
FOR OFFICIAL USE ONLY
Approved __________­­­­___________________________________ Date ____________________________ File Number _______________________________
Date Certificate Issued ____________________________________ Certificate Number ________________________________________________________
Remarks ________________________________________________________________________________________________________________
VSA 705 2016/04/11
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