Part I.

I A.B. [insert Address and Description] hereby claim to be registered as a Member of the Birmingham Gun Trade in respect of the Premises occupied by me, situate [here insert the Description and Situation of the Premises by the Street or Road, Number (if any), Town, Parish, or other Locality].

Dated

(Signed) A.B.

To the Law Clerk to the Guardians of the Birmingham Proof House.