Candidate's name	____________________________________________________________
I hereby certify that this candidate has completed all requirements and is entitled to receive the Hart and Crescent Award.
Counselor's signature	____________________________________________________________
Date	____________________________________________________________
Relationship to candidate (Priest/ess, parent, coven elder, etc.)	____________________________________________________________
Name and address where award should be sent	____________________________________________________________ ____________________________________________________________ ____________________________________________________________

Enclose a fee of $15.00, in the form of a check or money order payable to the Covenant of the Goddess, and mail to:

C.O.G./Hart and Crescent
P.O. Box 1226
Berkeley, CA 94704

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