Date ______________

(Please include application fee of $10.00)

LAST NAME _________________________ FIRST NAME ______________________

ADDRESS ______________________________________ P.O. BOX______________

CITY __________________________ STATE _____________ ZIP CODE____________

HOME PHONE ___________________ WORK/OFFICE PHONE __________________

E-MAIL ________________________________________________________________

MARITAL STATUS (Circle one) Married Single SEX M F

BIRTH DATE ___/___/___ (month/day/year)

CHECK ONE: Pastor _____ (How long?) _____ Associate Pastor _____ (How long?) _____

Layperson_____

CHECK PREDOMINANT CLASSIFICATION Caucasian ____Black_____

Hispanic ____American Indian _____Other _________________________

LEVEL OF EDUCATION (Check those that you have completed)

High School ______ College ______ Degree held __________

Graduate School ______ Degree held ___________

NAME OF CHURCH _____________________________________________________________

MAILING ADDRESS _____________________________________________________________

CITY _______________________________ STATE ________ ZIP CODE __________

YEARS IN MINISTRY ____________________________________________________________

DO YOU SUPPLEMENT YOUR INCOME WITH 20 HOURS OR MORE WORK PER WEEK? (Circle one) Yes No

AGE OF CHURCH ________________ AVERAGE MORNING ATTENDANCE _______________

Please mail completed form to: Institute for Servant Leadership, 6498 Pleasant River Drive, Dimondale, MI 48821. For more information, call Ken Wiedrick at (517) 646-0124.