Declaration of Acceptance of Islam

Assalamu Alaikum,

If you have accepted Islam and need a certificate with the "Declaration of Faith", please fill out this form and we will send you a certificate.
Your Name:*

First NameLast Name
Your Email:*
example@example.com
Your Phone Number:*
Please enter a valid phone number.
Date of Birth:*

MonthDayYear
Date
I hereby declare that I am above 18 years of age:*

YesNo
Date of acceptance of Islam*

MonthDayYear
Date
I testify and bear witness that there is no God except Allah, and that the Prophet Muhammad صلى الله عليه وسلم is His Prophet and Messenger*

AgreeDisagree
I accepted Islam under my own free will*

YesNo
I testify that everything on this document is true and accurate*

YesNo
Should be Empty: