This certifies that ___________________, having been duly examined concerning _____________ gifts, graces, and usefulness, and being deemed qualified for such service, is hereby made a _____________* according to the usages of The Wesleyan Church, for one year, provided that ____________ spirit, practice, and ministry are in keeping with the Scriptures and The Discipline of The Wesleyan Church.
By order and on behalf of the district conference of the _____________ District of The Wesleyan Church, this ______ day of __________, AD ________.
________________________ District Superintendent ________________________ District Secretary
(*Insert the proper term, namely licensed minister or ministerial student. This license may be renewed annually; and when so renewed notation shall be made on the reverse side of this form on which such renewal was ordered, and the same shall be attested by the signature of the district superintendent and the district secretary.)