Raw Score for this Application: out of - %

Q1. 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:

Q2. Please enter the following: Email
Email:

Q3. Date of birth? (MM/DD/YYYY)

Q4. Are you a believing Christian?
Yes
No

Q5. If NO, what are your religious beliefs? (Open box with box that grows as text grows- 100 words max.)

Q6. Are you a Pastor?
Yes
No

Q7. If Yes, how long?
Less than a year.
One to three years.
Four to five years
Six years plus
Not a Pastor

Q8. Date church was established?

Q9. Did you plant this church?
Yes
No

Q10. If not a Pastor, do you attend a church?
Yes
No

Q11. If YES, what church do you currently attend?

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

Q12. Church location: (Street Address, City, State, Zip Code, Telephone Number)

Q13. Pastor’s Name?

Q14. Church denomination?

Q15. How long have you been attending?

Q16. Are you a member?
Yes
No