This certifies that ___________________________ is a member in the Church of the Nazarene at ___________________ and, at h________ request, is hereby transferred to the Church of the Nazarene at _____________________ in the ___________________ District.
When the reception of this transfer is acknowledged by the receiving local church, membership in this local church will cease.
________________________________________________________
Pastor
________________________________________________________
Address
Date ______________________________
NOTE: A transfer is valid for three months only. ((111)