NAME______________________
ADDRESS___________________
CITY ______________________
STATE _____________________
ZIP CODE __________________
E-MAIL ____________________
WEB SITE __________________
ORDAINED BY WHICH CHURCH
OR DENOMINATION?
_____________________________
DATE OF ORDINATION
_____________________________
OPTIONAL INFORMATION
(Not required for membership in ICMC)
Phone # _____________________
Date of Birth __________________
Marital Status _________________
