Church Membership Form

SSRC MEMBERSHIP ENROLLMENT FORM

All information on this form is strictly confidential
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
E-mail*
example@example.com
Mobile Phone Number*

Area CodeNumber
Can we contact you via text/email?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Family
Marital Status*
Spouse Name

First NameLast Name
D.O.B.

MonthDayYear
Date
Children/Dependent
Full Name(s) and D.O.B.
What are some of your talents and/or giftings?*
Are you a born again Christian?*

YESNO
If YES, Could you share with us a short testimony of your salvation?
Have you been Baptized?

YesNo
If NO, would you like to be Baptized?

YesNo
All correspondence to Soul Saving Revival Center || P.O. Box 163 Buffalo, NY 14212 || E-mail: joinssrc@ssrcchurch.com || Office Number: (716) 856-7070 || Youtube/Facebook: SSRCBUFFALO or type Soul Saving Revival Center
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SSRC MEMBERSHIP ENROLLMENT FORM