Form 4

The Session of the _________ [name and location of the congregation]_______ has certified the following elders to be delegates to the meeting of _____ [name of the presbytery or synod] _________, meeting on the ______________________ day of ____________________ in the year ____________, at ______________ a.m./p.m., at ___________[location of the place of the meeting] _____________. The membership of the congregation as of the last day of December was _________________.

(This last sentence for congregation only.)

_______________________________, Teaching Elder _______________________________, Teaching Elder _______________________________, Ruling Elder _______________________________, Ruling Elder _______________________________, Ruling Elder––Alternate _______________________________, Ruling Elder––Alternate

Given this ___________________ day of _________________________ in the year ____________, by order of the Session.

_____________________________ ______________________________ Clerk of the Session Moderator of the Session