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?



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?



Q7. If Yes, how long?






Q8. Date church was established?


Q9. Did you plant this church?



Q10. If not a Pastor, do you attend a church?



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?



Q17. Marital Status?






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?



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.


Q25. Have you ever been convicted of a Felony or Misdemeanor? If yes, please explain.


Q26. Have you ever been or received First Offender’s status for a crime? If yes, please explain:


Q27. Do you have a history of drug or alcohol abuse?



Q28. Would you be willing to submit to drug testing? If no, please explain.


Q29. Is english your first language? If not, what is your first language?


Q30. Military Service
NAME BRANCH OF SERVICE HIGHEST RANK DATE ENTERED: DATE DISCHARGED: TYPE OF DISCHARGED: DD214 NUMBER:


Q31. I am registering for?



Q32. Gender?