Your name *

First Name

Last Name

Your date of birth

MM

DD

YYYY

Are you a student? *

Yes

No

Are you resident? *

Yes

No

Your address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your landline phone number

(###)

###

####

Your mobile phone number

(###)

###

####

Additional family member 1

First Name

Last Name

Date of birth

MM

DD

YYYY

Additional family member 2

First Name

Last Name

Date of birth

MM

DD

YYYY

Additional family member 3

First Name

Last Name

Date of birth

MM

DD

YYYY

Additional family member 4

First Name

Last Name

Date of birth

MM

DD

YYYY

Additional family member 5

First Name

Last Name

Date of birth

MM

DD

YYYY

By ticking this box, I agree to the Diocese of East Anglia using the information I have provided on this application solely for the purposes of processing this application. I understand that a copy of any subsequent Decree of Nullity arising from this application will be held indefinitely by the Diocese of East Anglia in secure storage strictly in accordance with the provisions of the UK Data Protection Act (2018) as to collection, handling, secure storage, use, retention and disposal of this data. I understand that my details will not be passed on to any third party. *

I have read and agree with the above statement