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Name of person preparing form:(*)

 

District:(*)

 

Name of Church and Church Number:(*)

 

Location:(*)

 

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):(*)