What is the address of your church/congregation? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Name *

First Name

Last Name

What is the primary phone number where we may reach you? *

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What is the next best phone number where you may be reached?

(###)

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Your Pastor's Name *

First Name

Last Name

Your Pastor's Phone Number *

(###)

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Do you have the authority to submit this application on behalf of the church listed above? *

Yes

No

Date *

MM

DD

YYYY