To the Right Reverend the Lord Bishop of (Diocese) and to his registrar,
I (Name of Proposer) of (Place) in the Parish of (Parish) in the County of (County). Do
hereby Certify that (A Meeting/Dwelling House) and Premises situate at (House Name)
in the Parish of (Parish) in the County of (County) and now in the holding and
occupation of (Name of Owner) are intended to be used as a place of Religious Worship,
by an Assembly or Congregation of Protestants; and I hereby request you to register and
record the same; according to the Provisions of an Act passed in the 52nd Year of the
Reign of his Majesty King George the Third (1812), entitled, "An Act to repeal certain
Acts, and amend other Acts, relating to Religious Worship and Assemblies, and persons
teaching and preaching therein"; and I hereby request a Certificate thereof, for which
shall be taken no more than two Shillings and Sixpence. Witness My Hand this (Date)
day of (Month) in the year of Our Lord, One Thousand Eight Hundred and (Year).
Signature.
One example held in Hereford Record Office was written to the Bishop of Hereford by Thomas Kington of The Hill, Castle Frome, Hereford for a license for the house of Henry Smith of the Hommingstreet, Ledbury, Hereford, on the 13th March 1835.
(Hereford Record Office HD8/11a)