Form 3

The ______________ [name of the presbytery] ___________________ has certified the following teaching elders to the meeting of Synod, on the _________________ day of ___________________ in the year ________________, at ______________ a.m./p.m., at ___________ [location of the place of the meeting] _________.

______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________

Given this ______________________ day of _________________________ in the year ______________, by order of the Presbytery.

_____________________________ ______________________________ Clerk of the Presbytery/ Moderator of the Presbytery/ Clerk of the Ad Interim Moderator of the Ad Interim Commission Commission