Religious Exemption Form - Connecticut Department Of Public Health Page 2

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ACKNOWLEDGEMENT
STATE OF CONNECTICUT
:
:
ss:
COUNTY OF _______________________
:
On this the_____ day of _____________, _____, before me, ____________________________the
undersigned officer, personally appeared ___________________ known to me (or satisfactorily proven)
to be the person whose name he or she subscribed to the within instrument and acknowledged that he or
she executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand.
____________________________________
Judge
Family Support Magistrate
Clerk/Deputy Clerk (include seal)
Town Clerk
Notary Public My Commission expires (______________)
Justice of the Peace
Commissioner of the Superior Court (bar no.__________)
School Nurse (license no.__________________________)

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