Last Name             

First Name

Middle Name

Date of Birth

Home Street Address   

City

State

Zip

Office Address

City

State

Zip

Telephone No

Home  (       )

Work  (      ) 

Fax  (      )

E-mail

Social Security No

o   Married             

o   Single

Spouse’s Name

If Yes, Date of Marriage

Children                                                                                 DOB

Children                                                                                 DOB

Licensed  with                                                                               Date

Ordained with                                                                                Date

Church name before entering ministry

City

State:

Presently serving (list church or organization and location

City

State:

Present Church Membership

City

State

Education

Name of School (Do not abbreviate)

City, State

Date                                                                                       

Major

Degree

Name of School (Do not abbreviate)

City, State 

Name of School (Do not abbreviate)

City, State 

Name of School (Do not abbreviate)

City, State 

Service Record

From                       To

Church or Institution (Include City and State)

Position

Chaplain        ¨ Yes       ¨ No  

Serving at

Branch of Service: Active      ¨ Yes       ¨ No     Current Rank:                                                                                       

¨ Air Force (active)                      ¨ Army (active)             ¨ Navy (active)             ¨ Veterans Administration Hospital  

¨ Air Force Reserve             ¨ Navy Reserve            ¨ Army National Guard        ¨ Civil Air Patrol          

¨ State Military Reserve               ¨ Other                                                                                         

The Evangelical Free Church of America (has) (does not have) my permission to release the information contained in this document.

Signature                                                                                                                                       Dated: