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

Action Type
	New
	Resubmission
		Kingdom
		Laurel	
	Change, if registered:
		release old device
		retain as badge
	Appeal (attach justification)                     
	Other (specify) 

Society Name	 
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)

(Note: the shield shape should be approximately 5 inches (12.7 cm) wide and 6 inches (15.2 cm) tall when printed)