Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATIONFull Name *FirstMiddleLastPreferred Name (If different from above)BirthdateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse's Full NameFirstLastSpouse's Preferred Name (If different from above)FirstLastSpouse's BirthdateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Wedding AnniversaryAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneWork PhoneCell PhoneEmail *Do you have children? (If so, please give name and ages)MINISTERIAL INFORMATIONFull name of the congregation(s) you currently pastorHow long have you pastored this congregation?What day are your worship services?Service timeBuilding in which your congregation meets:Church AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChurch Hall Phone NumberDescribe your current position:Full-time EmployedBi-VocationalPart-time EmployedFellowship Group FacilitatorPastoral Team MemberTemporary ContactRetired PastorOther (please explain belowDo you have a GCI camp in your are? If so, which one:Describe your congregation's involvement:Do you have a college degree? (Please describe)Are you currently taking a class from (ACCM) Ambassador College of Christian Ministry or (GCS) Grace Communion Seminary:YesNoIf yes, please list the class you are taking currently:Name of your treasurer (for emergency purposes only):FirstLastHome PhoneWork PhoneCell PhoneEmail *PERSONAL INTERESTSWhat hobbies or fun things do you do to relax? (Explain)HELPFUL INFORMATIONBest time of the day for me to call youMorningAfternoonEveningAnytimeBased on your personality and work style - what would you say best describes the degree of interaction you would like from me as your Regional Director:MonthlyBi-AnnuallyAnnuallyAs little as possibleNot real excited about you being my Regional DirectorWhenever there is a needHow can I best serve you: (Please feel free to speak openly)SignatureClear SignatureNameSubmit