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Complete this form when interviewing a male member to be ordained to an office in the
Aaronic Priesthood. The assigned representative brings this form to the ordination. After the
ordination, give the completed form to the clerk, who should use LCR to record the ordination
information and print a certificate for the member. Keep the form on file until after the next
membership audit.
Member Information
Name of person being ordained (surname[s], given names[s], suffix)
19 Apr 2004
Record Number
001-2319-7443
Unordained
Address
Phone
2974275
Stake or district
Deacon
19 Apr 2016
Interview Information
Signature of bishopric or branch presidency member
Ordinance Information
Ordained to the office of
Deacon
Person who performed the ordination
Record Number
Priesthood Office