Watchtower-Free, thanks for posting the form.
Where are you? I saw a nearly identical form being passed out in a congregation about two years ago. This was in Southern California.
At the time, because of the way the elders presented it, I got the idea that this was a local thing. From what I've read here on JWN since that time it is clear that this is NOT a local thing.
Again, the form the elders passed out nearly two years ago was nearly identical, except the "DESTROY AFTER USE" comment