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Name of person preparing form:(*)




Name of Church and Church Number:(*)




Mailing Address:(*)


Church Phone:(*)


Church Email:(*)


Pastor's Name:(*)


Pastor's Address:(*)


Pastor's Phone:(*)


Pastor's Email:(*)


Date Organized:(*)


Number of Charter Members:(*)


Of the charter members, how many were by profession of faith?(*)


Sponsored By (district, local church or churches):(*)