From Wesleyan Discipline
6040. Letter Given to Person Desiring to Withdraw from the Church (592; Gen. Bd. Policy on Ch. Disc. 5048).
This certifies that ____________, the bearer, has been up to this date a member of the ______________ Wesleyan Church, and being desirous of withdrawing from said Church, is hereby declared to be withdrawn.
By authority and in behalf of the ______________ Wesleyan Church, this ______ day of __________, AD ________.
________________________ Pastor ________________________ Local Church Secretary
(It is understood that this letter of withdrawal terminates the bearer’s membership in The Wesleyan Church immediately.)