KNOW ALL MEN BY THESE PRESENTS (which are intended to be enrolled in the Central Office of High Court of Justice in Northern Ireland) that I the undersigned Charene Michaela Poland, Student of 74a Scroggy Road, Limavady in the County of Londonderry now or lately called Charene Michaela Moore, a Commonwealth Citizen, WITNESS AND IT IS HEREBY DECLARED as follows:

1.	I absolutely and entirely renounce relinquish and abandon the use of my former surname of Moore and assume adopt and determine to take and use the surname of Poland in substitution for my former surname of Moore.
2.	I shall at all times hereafter in all records, deeds and documents and other writings and in all actions and proceedings as well as in all dealings and transactions and on all occasions whatsoever use and subscribe my the said name of Poland as my surname in substitution for my former surname of Moore so relinquished as aforesaid to the intent that I may hereafter be called known or distinguished not by my former surname of Moore but by the surname of Poland only.
3.	I authorize and require all persons at all times to designate, describe and address me by the adopted surname of Poland.

IN WITNESS whereof I have hereunto subscribed my christian or first names of Charene Michaela and my adopted and substituted surname of Poland and also my former surname of Moore and have affixed my seal this 21st day of October Two thousand and four.

SIGNED, SEALED and DELIVERED by the: said Charene Michaela Poland formerly known as Charene Michaela Moore