Action Type 
	New
	Resubmission
		Kingdom
		Laurel	
	Change, if registered:
		release old badge

		retain old badge(s)
	Appeal (attach justification)                     
	Other (specify) 

This name is (pick one):
	already registered
	submitted with this device 
	previously submitted from the Kingdom of

Society Name	 
Name this badge is to be associated with	
Legal name	
Address	
	
Branch Name		
Phone Number	Date of Birth	
E-mail Address	Date Submitted	
Consulting Herald	Herald's E-mail/Phone	

If using any restricted charges, please give Kingdom and date of eligibility for that charge.

Proposed Blazon  (Consult a herald if possible.  Use plain English if you don’t know how to blazon.)

Blazon as submitted on LoI 
(Kingdom Use Only)

	Is this badge jointly owned?		Yes		No
	If Yes, co-owner’s Society Name	

(Note: the square below should be approximately 4.5 inches (11.4 cm) wide when printed)