Raw Score for this Application: out of - %

Q1. Residence History

Q2. Please enter the following: Name, Address, Phone Numbers, Organization
First Name:

Last Name:

Client ID#:

Telephone (H):

Telephone (C):

Address:

City:

State or Province:

Postal Code:

Q3. Please enter the following: Email
Email:

Q4. Are you a Pastor?
Yes.
No.

Q5. If YES, how long?

Q6. Name of church:

Q7. Date church established:

Q8. Did you plant this church?

Q9. Church denomination (if applicable):

Q10. Church location: (Street Address, City, State, Zip Code, Telephone Number)

Q11. If you are not a Pastor, please record church location: (Street Address, City, State, Zip Code, Telephone Number)

Q12. Pastor’s name and church denomination?

Q13. How long have you been attending?

NAME OF Ministry	How long were you apart of this ministry?:	What role did you serve?:

Q14. Are you a member?
Yes
No.

Q15. If yes, how long have you been a member?

Q16. Social media networks, Please list the links to your personal Twitter, Facebook, and Linkedln accounts. (if applicable)

Q17. Marital status?
Single
Married
separated
Divorced

Q18. If Married, How Long? Divorced, Separated or Widowed? How Long?

Q19. If married, spouse's name? Cell phone number? Email address?

Q20. Do you have children? If yes, how many? If yes, what ages?

Q21. Do you have any litigation pending that has not reached a final verdict or resolution?
Yes
No.

Q22. If yes, please explain why?

Q23. Have you ever been convicted of a Felony?
Yes
No.

Q24. If yes, please explain why?

Q25. Have you ever been convicted of a Misdemeanor?
Yes
No.

Q26. If yes, please explain why?

Q27. Have you ever been or received First Offender’s status for a crime?
Yes
No

Q28. If yes, please explain why?

Q29. Do you have a history of drug or alcohol abuse?
Yes
No

Q30. If yes, please explain why?

Q31. Would you be willing to submit to drug testing?
Yes
No

Q32. If no, please explain why?