Applicant Title Applicant TitleMr.Mrs.Miss

Applicant First Name

Applicant Last Name

Applicant Home Phone Number

Applicant Cell Number

Applicant Email

Applicant Website

Applicant Address

Date of birth (YYYY-MM-DD)

Are you over the age of 75 years? Are you over the age of 75 years? Yes No

Marital Status Marital Status Single Married Divorced Remarried

Credential you hold? Credential you hold? Commissioned Christian Worker Licensed Ordination

What has been your field of ministry during the past year?

Are you in active ministry? Are you in active ministry? Yes No

Ministry/Church Name

Ministry/Church Phone Number

Ministry/Church Cell Number

Ministry/Church Email

Ministry/Church Website

Ministry/Church Address

Date you attended the last Provincial or National Convention?

Do you find it necessary to subsidize your income with secular work? Do you find it necessary to subsidize your income with secular work? Yes No

Does the reason for your original credential Commissioned Christian Worker, License or Ordination still apply? Does the reason for your original credential Commissioned Christian Worker, License or Ordination still apply? Yes No

If not, give the reason.

Do you have a Provincial Certificate to perform marriages? Do you have a Provincial Certificate to perform marriages? Yes No

Please supply a photo of yourself. You can email it to [email protected] or send it by regular mail. Please supply a photo of yourself. You can email it to [email protected] or send it by regular mail. By checking this box, I (the Applicant) confirm I have sent (or will send shortly) a recent picture of myself by email to [email protected], or will send it by regular mail.

Sponsoring Church Name

Sponsoring Church Phone Number

Sponsoring Church Cell Number

Sponsoring Church Email

Sponsoring Church Website

Sponsoring Church Address

Sponsoring Pastor First Name

Sponsoring Pastor Last Name

Sponsoring Pastor Phone Number

Sponsoring Pastor Cell Number

Sponsoring Pastor Email

Sponsoring Pastor Website

Sponsoring Pastor Address

Validation (Applicant) Validation (Applicant) I hereby certify that the answers to the above questions are true and correct to the best of my knowledge.

Validation (Sponsoring Pastor) Validation (Sponsoring Pastor) I hereby certify that the answers to the above questions are true and correct to the best of my knowledge.

Validation (Sponsoring Church Secretary) Validation (Sponsoring Church Secretary) I hereby certify that the answers to the above questions are true and correct to the best of my knowledge.