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

Q17. Marital Status?
Single
Married
Seperated
Divorced
Widowed

Q18. If married, how long?

Q19. If divorced, separated or widowed? How long?

Q20. If Married, Spouse’s Name: (First, Middle, Last)

Q21. Spouse’s Email Address? Spouse’s Cell Phone?

Q22. Do you have children?
Yes
No

Q23. If yes, how many? What are their ages?

Q24. Do you have any litigation pending that has not reached a final verdict or resolution? If yes, please explain.