Comes now, _________________________, Sui Juris, Free, Natural Flesh and Blood

Human Being, state Citizen of the New Jersey Republic. Be it known to all courts,
governments, and other parties that:

Being a person of Strong Christian Morals, it is against my Deep, Sincerely Held,

Religious Convictions to accept the injection of any foreign substance into my Body. This
includes, but is not limited to, any and all, Vaccinations, Shots, Tests for Diseases, Oral
Vaccines, Epidermal Patches and in any other way that Live or Killed Bacterium, Viruses,
Pathogens, Germs, or any other Microorganisms, may be introduced into or upon my
body.

This written statement to exempt myself from the immunization requirement, and the
Mantoux (PPD) Tuberculin Test, because I hold genuine and sincere personal religious
beliefs which are inconsistent with these medical procedures and experimentation. The
practice of vaccination and the injection of any foreign substance is contrary to my
conscientiously held religious beliefs and practices, and violates the free exercise of my
religious principles.

The attenuated virus used to produce the Rubella vaccine (RA27/3) was obtained from an
aborted fetus and then cultivated on fetal tissue from another aborted baby (WI-38), and
is also in the rubella portion of the MMR-II vaccine. The Chickenpox vaccine containing
WI-38, MRC-5 and Hepatitis-A vaccine (MRC-5) were obtained from human babies
that were electively aborted. A conflict arises because my religious convictions are
predicated on the belief that all life is sacred. God's commandment "Thou Shall Not
Kill" applies to the practice of abortion. The acceptance of these vaccines promotes
abortion and violates the Sixth Commandment of "Thou Shall Not Kill". The Hepatitis-
B vaccine protects against a disease that is only transmitted through multiple sexual
partners or street IV drug users. The acceptance of this vaccine promotes sexual
promiscuity and immoral behavior in direct contradiction to the teachings of my faith.

I, {First and Last name}, am exercising my rights under the First Amendment of the US
Constitution and [insert New Jersey college Statute/s here]; to receive Religious
Exemption from Vaccination & testing.

Applicable law has been interpreted to mean that a religious belief is subject to protection
even though no religious group espouses such beliefs or the fact that the religious group
to which the individual professes to belong may not advocate or require such belief. Title
VII of the Civil Rights Act of 1964 as amended Nov. 1, 1980; Part 1605.1-Guidelines on
Discrimination Because of Religion.

The Lord Jesus Christ and Our Creator are the only source of protection of my body and
that of my family that I can accept.

I affirm that vaccination & injections of foreign proteins conflict with my religious belief
as stated above. Therefore, I would request that you accommodate my religious beliefs
and practices by exempting me from the college vaccination and TB testing requirement.
Rest assured that I do practice a form of immunization that keeps my immune system
strong and is in keeping with Biblical principles.

Further Affiant Saith Not

The use of notary below is for identification only, and such use does NOT grant any
jurisdiction to anyone.

Subscribed and sworn, without prejudice, and with all rights reserved, (Print Name
Below)

_______________________________________________________________,
Principal, by Special Appearance, in Propria Persona, proceeding Sui Juris.

_______________________________
Signature of Affiant

ACKNOWLEDGMENT

state of New Jersey

county of _________________:

On this _______ day of ______________, 200__, before me

personally appeared __________________________________, to me known to be the

person described in and who executed the foregoing instrument and acknowledged that
he executed the same as his free act and deed, for the purposes therein set forth.

_______________________________________
(Notary Public)

My Commission Expires ______________________________, 200___