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I, do hereby declare that –
1. I am baptised;
2. I am a member of the Anglican Church of Australia and of no Church which is not in communion with this Church;
3. I am at least 18 years of age;
4. I have been for a period of not less than three months and am an accustomed worshipper in the Parish of Bulimba.
5. I claim to be a Parishioner of the said Parish;
6. I am not an Elector for any other Parish;
7. I am a communicant and claim to be an Elector of the said Parish.