REGISTRATION

Pastor's Name *

First Name

Last Name

Spouse's Name

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone *

(###)

###

####

Church Fax

(###)

###

####

Date of Birth *

MM

DD

YYYY

Anniversary Date (if married)

MM

DD

YYYY

Currently on Staff? *

Yes

No

Ministry status (inactive)? *

Yes

No

Ministry status (in transition)? *

Yes

No

Desire change in ministerial status? *

Yes

No

Available or seeking pastorate? *

Yes

No

Available for interim pastor? *

Yes

No

Available for pulpit supply? *

Yes

No

Warner Pacific University Alumnus? *

Yes

No

Signing Date *

Select the date you signed the Covenant Agreement for Ordination.

MM

DD

YYYY

Assembly Bestowing Credentials *

Check the boxes below to state your Credentialing Assembly and the Credentialing Assembly's Chair.

Church of God Northwest

Pastor Rich LaMar, Credentials Chair