Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation*
Employer
Tax ID #
S. S. #*
Name of Your Pastor*
First Last
Church Name*
Church Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name*
First Last
Are You Married?*
- Yes
- No
Spouse's Name
First Last
Wedding Date
Date Format: MM slash DD slash YYYY
Number of Dependents*
Dependent 1 Name
First Last
Dependent 1 Birthdate
Date Format: MM slash DD slash YYYY
Dependent 2 Name
First Last
Dependent 2 Birthdate
Date Format: MM slash DD slash YYYY
Dependent 3 Name
First Last
Dependent 3 Birthdate
Date Format: MM slash DD slash YYYY
Is your spouse in agreement with your desire to be a part of CCI?
- Yes
- No
Have you been divorced?*
- Yes
- No
Has your Spouse been divorced?
- Yes
- No
If you answered "yes" to any of the above questions, please attach a letter of explanation.
Have you ever been involved in or charged with homosexuality or immoral conduct of any nature?*
- Yes
- No
If so, please attach a letter of explanation.
Have you been ordained?*
- Yes
- No
By whom?
Date
Date Format: MM slash DD slash YYYY
Name of Organization
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please attach a copy of ordination certificate if possible.
What calling in ministry are you presently following?*
List Spiritual Gifts, Skills, and Talents.*
Name of other religious organizations where you hold membership:
Name
Phone Number
Name
Phone Number
Name
Phone Number
How long have you been associated with these organizations?
Please select the license you desire with CCI.*
- Ordination
- License
- Christian Worker
Are you wishing to transfer credentials from some other organization over to CCI?*
- Yes
- No
Name of Organization
Phone Number
Are you willing to abide by the rules and by-laws of CCI?*
- Yes
- No
Briefly describe why you would like to be a member of CCI.*
Recommended by Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Education and Experience:*
Additional Comments
Please upload a current photograph of yourself (if possible).
I understand that the Annual membership fee is due One month prior to the date of expiration on ministerial Credential Card. ($50.00 for Ordination, $45 for Licensed, $40 for Christian Worker)*
- Yes
- No
Signature of Applicant*
Date*
Date Format: MM slash DD slash YYYY
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