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apply for membership in a Scientology Religious Order and for active participation as a staff member within the Church of Scientology of
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:
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
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.
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
(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.
I FURTHERUNDERSTANDTHAT ALL CHURCH STAFFMEMBERS INCLUDING MYSELF,ARE
MEMBERS OF A RELIGIOUSORDER;THAT THEY SERVEPURSUANTTO THEIRRELIGIOUS
OBLIGATIONS AND NOT IN