Raw Score for this Application: 0 out of 62 - 0% <br /><br/>Q1.  Please enter the following: First Name, Last Name  <br/><b> First Name:</b><input type="text" name="fname" value="ggg" size="40" /><br/> <br />
                <b>Last Name:</b> <input type="text" name="lname" value="ggg" size="40" /> <br/><br/>
                <b>Client ID#:</b> <input type="text" name="pat_id" value="100" size="40" /> <br/><br/>
               <!--- <b>Organization:</b> <input type="text" name="company" value="ggg" size="40" /> <br/><br/>
                <b>Telephone (W):</b> <input type="text" name="phoneW" value="" size="40" /> <br/><br/>  -->
                <b>Telephone (H):</b> <input type="text" name="phoneH" value="" size="40" /> <br/><br/>
                <b>Telephone (C):</b> <input type="text" name="phoneC" value="" size="40" /> <br/><br/>
           <!--     <b>Telephone (F):</b> <input type="text" name="phoneF" value="" size="40" /> <br/><br/>  -->
                <b>Address:</b> <input type="text" name="addressH" value="" size="40" /> <br/><br/>
                <b>City:</b><input type="text" name="cityH" value="" size="40" /> <br/><br/>
                <b>State or Province:</b> <br /> <br />
                <b>Postal Code:</b> <input type="text" name="zipH" value="" size="40" /> <br/><br/><br />Q2. Residence History  <br/><br />Q3. Title  <br/> <input type="text" name="3" value="Input" size="40" /><br/>
      <br />Q4. Gender  <br/><input type="radio" id="1149" value="1149" name="4" checked=""> <label for="1149"> Male. </label><br />
    <input type="radio" id="1150" value="1150" name="4" checked=""> <label for="1150"> Female. </label><br />
    <br />Q5. Are you a Pastor?   <br/><input type="radio" id="1151" value="1151" name="5" checked=""> <label for="1151"> Yes </label><br />
    <input type="radio" id="1152" value="1152" name="5" checked=""> <label for="1152"> No. </label><br />
    <br />Q6. How long have you been a Pastor?  <br/> <input type="text" name="6" value="Input" size="40" /><br/>
      <br />Q7. Name of the church?   <br/> <input type="text" name="7" value="Input" size="40" /><br/>
      <br />Q8. Date the church was established?  <br/> <input type="text" name="8" value="Input" size="40" /><br/>
      <br />Q9. Did you plant this church?  <br/> <input type="text" name="9" value="Input" size="40" /><br/>
      <br />Q10. Church location: (Street Address, City, State, Zip Code, Telephone Number)  <br/> <input type="text" name="10" value="Input" size="40" /><br/>
      <br />Q11. Church denomination (if applicable):  <br/> <input type="text" name="11" value="Input" size="40" /><br/>
      <br />Q12. If you are not a Pastor, what church do you currently attend?  <br/> <input type="text" name="12" value="Input" size="40" /><br/>
      <br />Q13. Church location: (Street Address, City, State, Zip Code, Telephone Number)  <br/> <input type="text" name="13" value="Input" size="40" /><br/>
      <br />Q14. Pastor's Name?  <br/> <input type="text" name="14" value="Input" size="40" /><br/>
      <br />Q15. Church denomination (if applicable):  <br/> <input type="text" name="15" value="Input" size="40" /><br/>
      <br />Q16. How long have you been attending?   <br/> <input type="text" name="16" value="Input" size="40" /><br/>
      <br />Q17. Are you a member?  <br/><input type="radio" id="1164" value="1164" name="17" checked=""> <label for="1164"> Yes </label><br />
    <input type="radio" id="1165" value="1165" name="17" checked=""> <label for="1165"> No </label><br />
    <br />Q18. How long have you been a member?   <br/> <input type="text" name="18" value="Input" size="40" /><br/>
      <br />Q19. Social media networks, Please list the links to your personal Twitter, Facebook, and Linkedln accounts. (if applicable)  <br/> <input type="text" name="19" value="Input" size="40" /><br/>
      <br />Q20. Marital Status?  <br/><input type="radio" id="1168" value="1168" name="20" checked=""> <label for="1168"> Single </label><br />
    <input type="radio" id="1169" value="1169" name="20" checked=""> <label for="1169"> Married </label><br />
    <input type="radio" id="1170" value="1170" name="20" checked=""> <label for="1170"> Separated </label><br />
    <input type="radio" id="1171" value="1171" name="20" checked=""> <label for="1171"> Divorced </label><br />
    <input type="radio" id="1172" value="1172" name="20" checked=""> <label for="1172"> Widowed </label><br />
    <br />Q21. If married, how long? If divorced, separated, or widowed? How long?  <br/> <input type="text" name="21" value="Input" size="40" /><br/>
      <br />Q22. If married, spouse's name? (First, Middle, Last)  <br/> <input type="text" name="22" value="Input" size="40" /><br/>
      <br />Q23. Spouse's email address and cell phone number?  <br/> <input type="text" name="23" value="Input" size="40" /><br/>
      <br />Q24. Do you have kids?  <br/><input type="radio" id="1176" value="1176" name="24" checked=""> <label for="1176"> Yes </label><br />
    <input type="radio" id="1177" value="1177" name="24" checked=""> <label for="1177"> No </label><br />
    <br />Q25. If yes, how many?  <br/><input type="radio" id="1178" value="1178" name="25" checked=""> <label for="1178"> One child </label><br />
    <input type="radio" id="1179" value="1179" name="25" checked=""> <label for="1179"> Two or more children </label><br />
    <input type="radio" id="1180" value="1180" name="25" checked=""> <label for="1180"> None </label><br />
    <br />Q26. What are their ages?  <br/> <input type="text" name="26" value="Input" size="40" /><br/>
      <br />Q27. Do you have any litigation pending that has not reached a final verdict or resolution?   <br/><input type="radio" id="1182" value="1182" name="27" checked=""> <label for="1182"> Yes </label><br />
    <input type="radio" id="1183" value="1183" name="27" checked=""> <label for="1183"> No. </label><br />
    <br />Q28. If yes, please explain why?   <br/> <input type="text" name="28" value="Input" size="40" /><br/>
      <br />Q29. Have you ever been convicted of a Felony?   <br/><input type="radio" id="1185" value="1185" name="29" checked=""> <label for="1185"> Yes </label><br />
    <input type="radio" id="1186" value="1186" name="29" checked=""> <label for="1186"> No </label><br />
    <br />Q30. If yes, please explain why?   <br/> <input type="text" name="30" value="Input" size="40" /><br/>
      <br />Q31. Have you ever been convicted of a Misdemeanor?   <br/><input type="radio" id="1188" value="1188" name="31" checked=""> <label for="1188"> Yes </label><br />
    <input type="radio" id="1189" value="1189" name="31" checked=""> <label for="1189"> No </label><br />
    <br />Q32. If yes, please explain why?   <br/> <input type="text" name="32" value="Input" size="40" /><br/>
      <br />Q33. Have you ever been or received First Offender’s status for a crime?   <br/><input type="radio" id="1191" value="1191" name="33" checked=""> <label for="1191"> Yes </label><br />
    <input type="radio" id="1192" value="1192" name="33" checked=""> <label for="1192"> No </label><br />
    <br />Q34. If yes, please explain why?   <br/> <input type="text" name="34" value="Input" size="40" /><br/>
      <br />Q35. Do you have a history of drug or alcohol abuse?   <br/><input type="radio" id="1194" value="1194" name="35" checked=""> <label for="1194"> Yes </label><br />
    <input type="radio" id="1195" value="1195" name="35" checked=""> <label for="1195"> No </label><br />
    <br />Q36. If yes, please explain why?  <br/> <input type="text" name="36" value="Input" size="40" /><br/>
      <br />Q37. Would you be willing to submit to drug testing?  <br/><input type="radio" id="1197" value="1197" name="37" checked=""> <label for="1197"> Yes </label><br />
    <input type="radio" id="1198" value="1198" name="37" checked=""> <label for="1198"> No </label><br />
    <br />Q38.  If no, please explain why?  <br/> <input type="text" name="38" value="Input" size="40" /><br/>
      <br />Q39. Did you graduate from High School or Vocational School?   <br/>
                    <textarea rows="3" name="39" cols="50" style="margin-right: 40px; vertical-align: middle;">Input</textarea>
        <br /><br />Q40. Most recent College/Ministry/School attended:   <br/>
            
<table border="1" cellpadding="1" cellspacing="0" ><thead>
	
	<tr>
		<td><b>SCHOOL’S NAME</b></td>
        <td>
		<b>SCHOOL’S CITY, STATE</b></td>
		<td>
		<b>FROM:</b></td>
		<td>
		<b>TO:</b></td>
		<td>
		<b>FIELD OF STUDY:</b></td>
		<td>
	   <b>	DEGREE/DIPLOMA:</b></td>
	</tr> </thead><tbody>
            
            

</tbody></table>         
           <br /><br />Q41. Additional College/Ministry/School attended:  <br/>
            
<table border="1" cellpadding="1" cellspacing="0" ><thead>
	
	<tr>
		<td><b>SCHOOL’S NAME</b></td>
        <td>
		<b>SCHOOL’S CITY, STATE</b></td>
		<td>
		<b>FROM:</b></td>
		<td>
		<b>TO:</b></td>
		<td>
		<b>FIELD OF STUDY:</b></td>
		<td>
	   <b>	DEGREE/DIPLOMA:</b></td>
	</tr> </thead><tbody>
            
            

</tbody></table>         
           <br /><br />Q42. Do you speak any other languages?  <br/> <input type="text" name="42" value="Input" size="40" /><br/>
      <br />Q43. Military Service  <br/>
            
<table cellspacing="0" cellpadding="1" border="1"   id="MILT"><thead>
	
	<tr>
		<td>
		<b>NAME BRANCH OF SERVICE</b></td>

       <td>
		<b>HIGHEST RANK</b></td>

		<td>
		<b>DATE ENTERED:</b></td>

	<td>
		<b>DATE DISCHARGED:</b></td>

		<td> 
		<b>TYPE OF DISCHARGED:</b></td>

		<td>
	   <b>	DD214 NUMBER:</b></td>

	</tr> </thead><tbody>

            

</tbody></table>         
            
           <br /><br />Q44. At what age did you accept Christ?  <br/> <input type="text" name="44" value="Input" size="40" /><br/>
      <br />Q45. Do you believe that salvation of mankind comes only by confessing the Lord Jesus Christ and believing that God raised Him from the dead?   <br/><input type="radio" id="1211" value="1211" name="48" checked=""> <label for="1211"> Yes </label><br />
    <input type="radio" id="1212" value="1212" name="48" checked=""> <label for="1212"> No </label><br />
    <br />Q46. If no, please explain why?  <br/> <input type="text" name="49" value="Input" size="40" /><br/>
      <br />Q47. Do you believe in Jesus Christ’s bodily resurrection and ascension to the right hand of the Father in heaven?   <br/><input type="radio" id="1214" value="1214" name="50" checked=""> <label for="1214"> Yes </label><br />
    <input type="radio" id="1215" value="1215" name="50" checked=""> <label for="1215"> No </label><br />
    <br />Q48. If no, please explain why?  <br/> <input type="text" name="51" value="Input" size="40" /><br/>
      <br />Q49. Do you believe in the resurrection of the dead to either eternal life with Jesus for the saved or eternal damnation in hell for the unbelieving lost?   <br/><input type="radio" id="1217" value="1217" name="52" checked=""> <label for="1217"> Yes </label><br />
    <input type="radio" id="1218" value="1218" name="52" checked=""> <label for="1218"> No </label><br />
    <br />Q50. If no, please explain why?  <br/> <input type="text" name="53" value="Input" size="40" /><br/>
      <br />Q51. Do you believe in the deity, virgin birth, and perfect and sinless life of Jesus Christ?   <br/><input type="radio" id="1220" value="1220" name="54" checked=""> <label for="1220"> Yes </label><br />
    <input type="radio" id="1221" value="1221" name="54" checked=""> <label for="1221"> No </label><br />
    <br />Q52. If no, please explain why?  <br/> <input type="text" name="55" value="Input" size="40" /><br/>
      <br />Q53. Do you believe in the supernatural work in miracles and healing of Jesus Christ?   <br/><input type="radio" id="1223" value="1223" name="56" checked=""> <label for="1223"> Yes </label><br />
    <input type="radio" id="1224" value="1224" name="56" checked=""> <label for="1224"> No </label><br />
    <br />Q54. If no, please explain why?  <br/> <input type="text" name="57" value="" size="40" /><br/>
      <br />Q55. Do you believe in the substitutionary death of Jesus Christ and His bloodshed which atones for sins of the world?   <br/><input type="radio" id="1226" value="1226" name="58" checked=""> <label for="1226"> Yes </label><br />
    <input type="radio" id="1227" value="1227" name="58" checked=""> <label for="1227"> No </label><br />
    <br />Q56. If no, please explain why?  <br/> <input type="text" name="59" value="" size="40" /><br/>
      <br />Q57. Do you believe in the personal return of Jesus Christ in power and glory to rapture a mature church?  <br/><input type="radio" id="1229" value="1229" name="60" checked=""> <label for="1229"> Yes </label><br />
    <input type="radio" id="1230" value="1230" name="60" checked=""> <label for="1230"> No </label><br />
    <br />Q58. If no, please explain why?   <br/> <input type="text" name="61" value="" size="40" /><br/>
      <br />Q59. Do you believe in the observance of the Eucharist (Holy Communion) and in the ministry and baptism of the Holy Spirit, empowering and enabling the Christian to live a holy life in this present world and to minister as Jesus ministered?   <br/><input type="radio" id="1232" value="1232" name="62" checked=""> <label for="1232"> Yes </label><br />
    <input type="radio" id="1233" value="1233" name="62" checked=""> <label for="1233"> No </label><br />
    <br />Q60. If no, please explain why?  <br/> <input type="text" name="63" value="" size="40" /><br/>
      <br />Q61. Do you believe that the Holy Bible (Old and New Testament) is the inspired, inerrant and only infallible, authoritative word of God and the final authority in faith and conduct?  <br/><input type="radio" id="1235" value="1235" name="64" checked=""> <label for="1235"> Yes </label><br />
    <input type="radio" id="1236" value="1236" name="64" checked=""> <label for="1236"> No </label><br />
    <br />Q62. If no, please explain why?  <br/> <input type="text" name="65" value="" size="40" /><br/>
      <br />Q63. Do you believe there is only one true God, eternally existent and manifested in the triune Godhead, three persons equal in power and purpose and authority: God the Father, God the Son (Jesus Christ) and God the Holy Spirit?  <br/><input type="radio" id="1238" value="1238" name="66" checked=""> <label for="1238"> Yes </label><br />
    <input type="radio" id="1239" value="1239" name="66" checked=""> <label for="1239"> No </label><br />
    <br />Q64. If no, please explain why?  <br/> <input type="text" name="67" value="" size="40" /><br/>
      <br />Q65. Do you believe all have sinned and come short of the glory of God and are in need of salvation?   <br/><input type="radio" id="1241" value="1241" name="68" checked=""> <label for="1241"> Yes </label><br />
    <input type="radio" id="1242" value="1242" name="68" checked=""> <label for="1242"> No </label><br />
    <br />Q66. If no, please explain why?   <br/> <input type="text" name="69" value="" size="40" /><br/>
      <br />