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| title=Submit Your Testimony of Leaving Islam
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| namePattern={{{apostatename}}} - Former Muslim
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| instructions={{Template:Newapostate/guidelines}}
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| apostatename|Pseudonym (nickname)|text|Pseudonym
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| fullname|Real name (optional)|text|Real name (optional)
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| gender|Gender|radio|Gender|items=Male;Female
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| age|Current Age|text|Current Age
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| countryoforigin|Country of Origin|select|Country of Origin|items=-- Select --;Frequently Used;----------;Australia;Bangladesh;Canada;Egypt;India;Indonesia;Iran;Malaysia;Morocco;Pakistan;Saudi Arabia;Turkey;United Kingdom;United States;----------;FULL LIST;----------;Afghanistan;Albania;Algeria;American Samoa;Andorra;Angola;Anguilla;Antigua and Barbuda;Argentina;Armenia;Aruba;Australia;Austria;Azerbaijan;Bahamas;Bahrain;Bangladesh;Barbados;Belarus;Belgium;Belize;Benin;Bermuda;Bhutan;Bolivia;Bosnia and Herzegovina;Botswana;Brazil;British Virgin Islands;Brunei;Bulgaria;Burkina Faso;Burundi;Cambodia;Cameroon;Canada;Cape Verde;Cayman Islands;Central African Republic;Chad;Chile;Colombia;Comoros;Cook Islands;Costa Rica;Côte d'Ivoire;Croatia;Cuba;Cyprus;Czech Republic;Dem. Rep. of Congo;Denmark;Djibouti;Dominica;Dominican Republic;East Timor;Ecuador;Egypt;El Salvador;Equatorial Guinea;Eritrea;Estonia;Ethiopia;Falkland Islands;Faroe Islands;Federated States of Micronesia;Fiji;Finland;France;Gabon;Gambia;Georgia;Germany;Ghana;Gibraltar;Greece;Greenland;Grenada;Guam;Guatemala;Guernsey;Guinea;Guinea-Bissau;Guyana;Haiti;Honduras;Hong Kong;Hungary;Iceland;India;Indonesia;Iran;Iraq;Ireland;Isle of Man;Israel;Italy;Jamaica;Japan;Jersey;Jordan;Kazakhstan;Kenya;Kiribati;Kurdistan;Kuwait;Kyrgyzstan;Laos;Latvia;Lebanon;Lesotho;Liberia;Libya;Liechtenstein;Lithuania;Luxembourg;Macau;Madagascar;Malawi;Malaysia;Maldives;Mali;Malta;Marshall Islands;Mauritania;Mauritius;Mexico;Moldova;Monaco;Mongolia;Montenegro;Montserrat;Morocco;Mozambique;Myanmar (Burma);Namibia;Nauru;Nepal;Netherlands;Netherlands Antilles;New Zealand;Nicaragua;Niger;Nigeria;Niue;North Korea;Northern Mariana Islands;Norway;Oman;Pakistan;Palau;Palestinian Authority area;Panama;Papua New Guinea;Paraguay;People's Republic of China;Peru;Philippines;Pitcairn Islands;Poland;Portugal;Puerto Rico;Qatar;Republic of Macedonia;Republic of the Congo;Romania;Russia;Rwanda;Saint Helena;Saint Kitts and Nevis;Saint Lucia;Saint Vincent and the Grenadines;Samoa;San Marino;São Tomé and Príncipe;Saudi Arabia;Senegal;Serbia;Seychelles;Sierra Leone;Singapore;Slovakia;Slovenia;Solomon Islands;Somalia;South Africa;South Korea;Spain;Sri Lanka;Sudan;Suriname;Swaziland;Sweden;Switzerland;Syria;Taiwan;Tajikistan;Tanzania;Thailand;Togo;Tokelau;Tonga;Trinidad and Tobago;Tunisia;Turkey;Turkmenistan;Turks and Caicos Islands;Tuvalu;U.S. Virgin Islands;Uganda;Ukraine;United Arab Emirates;United Kingdom;United States;Uruguay;Uzbekistan;Vanuatu;Vatican City;Venezuela;Vietnam;Western Sahara;Yemen;Zambia;Zimbabwe
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| countryofresidence|Country of Residence (ignore if same as above)|select|Country of Residence|items=-- Select --;Frequently Used;----------;Australia;Bangladesh;Canada;Egypt;India;Indonesia;Iran;Malaysia;Morocco;Pakistan;Saudi Arabia;Turkey;United Kingdom;United States;----------;FULL LIST;----------;Afghanistan;Albania;Algeria;American Samoa;Andorra;Angola;Anguilla;Antigua and Barbuda;Argentina;Armenia;Aruba;Australia;Austria;Azerbaijan;Bahamas;Bahrain;Bangladesh;Barbados;Belarus;Belgium;Belize;Benin;Bermuda;Bhutan;Bolivia;Bosnia and Herzegovina;Botswana;Brazil;British Virgin Islands;Brunei;Bulgaria;Burkina Faso;Burundi;Cambodia;Cameroon;Canada;Cape Verde;Cayman Islands;Central African Republic;Chad;Chile;Colombia;Comoros;Cook Islands;Costa Rica;Côte d'Ivoire;Croatia;Cuba;Cyprus;Czech Republic;Dem. Rep. of Congo;Denmark;Djibouti;Dominica;Dominican Republic;East Timor;Ecuador;Egypt;El Salvador;Equatorial Guinea;Eritrea;Estonia;Ethiopia;Falkland Islands;Faroe Islands;Federated States of Micronesia;Fiji;Finland;France;Gabon;Gambia;Georgia;Germany;Ghana;Gibraltar;Greece;Greenland;Grenada;Guam;Guatemala;Guernsey;Guinea;Guinea-Bissau;Guyana;Haiti;Honduras;Hong Kong;Hungary;Iceland;India;Indonesia;Iran;Iraq;Ireland;Isle of Man;Israel;Italy;Jamaica;Japan;Jersey;Jordan;Kazakhstan;Kenya;Kiribati;Kurdistan;Kuwait;Kyrgyzstan;Laos;Latvia;Lebanon;Lesotho;Liberia;Libya;Liechtenstein;Lithuania;Luxembourg;Macau;Madagascar;Malawi;Malaysia;Maldives;Mali;Malta;Marshall Islands;Mauritania;Mauritius;Mexico;Moldova;Monaco;Mongolia;Montenegro;Montserrat;Morocco;Mozambique;Myanmar (Burma);Namibia;Nauru;Nepal;Netherlands;Netherlands Antilles;New Zealand;Nicaragua;Niger;Nigeria;Niue;North Korea;Northern Mariana Islands;Norway;Oman;Pakistan;Palau;Palestinian Authority area;Panama;Papua New Guinea;Paraguay;People's Republic of China;Peru;Philippines;Pitcairn Islands;Poland;Portugal;Puerto Rico;Qatar;Republic of Macedonia;Republic of the Congo;Romania;Russia;Rwanda;Saint Helena;Saint Kitts and Nevis;Saint Lucia;Saint Vincent and the Grenadines;Samoa;San Marino;São Tomé and Príncipe;Saudi Arabia;Senegal;Serbia;Seychelles;Sierra Leone;Singapore;Slovakia;Slovenia;Solomon Islands;Somalia;South Africa;South Korea;Spain;Sri Lanka;Sudan;Suriname;Swaziland;Sweden;Switzerland;Syria;Taiwan;Tajikistan;Tanzania;Thailand;Togo;Tokelau;Tonga;Trinidad and Tobago;Tunisia;Turkey;Turkmenistan;Turks and Caicos Islands;Tuvalu;U.S. Virgin Islands;Uganda;Ukraine;United Arab Emirates;United Kingdom;United States;Uruguay;Uzbekistan;Vanuatu;Vatican City;Venezuela;Vietnam;Western Sahara;Yemen;Zambia;Zimbabwe
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| bornmuslimorconvert|Were you born into Islam or a convert to Islam?|radio|Born or convert|items=Born into Islam;Convert to Islam
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| leftislamatage|Left Islam at age|text|Left Islam at age|size=5
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| currentworldview|Current worldview (see note #10 above if your choice is not listed)|select|Current worldview|items=-- Select --;Agnosticism;Atheism;Buddhism;Christianity;Christianity (Catholic);Christianity (Protestant);Christianity (Orthodox);Confucianism;Deism;Hinduism;Humanism;Humanism (Agnostic);Humanism (Atheist);Jainism;Judaism;Shinto;Sikhism;Taoism;Theism;Zoroastrianism;Withheld
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| parentsworldview|Parents' worldview|select|Parents' worldview|items=-- Select --;Agnosticism;Atheism;Buddhism;Christianity;Christianity (Catholic);Christianity (Protestant);Christianity (Orthodox);Confucianism;Deism;Hinduism;Humanism;Humanism (Agnostic);Humanism (Atheist);Islam;Jainism;Judaism;Shinto;Sikhism;Taoism;Theism;Zoroastrianism
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| influences|Influences|text|Influences|size=60
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| otherinterests|Interests/Hobbies|text|Interests/Hobbies|size=60
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| websiteurl|Website/blog URL|text|Website/blog URL|size=40
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| testimony|Testimony of Leaving Islam|textarea|Explain why you left Islam. Please give as much detail as possible and make sure you have read the guidelines above:|rows=18,cols=10
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