Minister Information Form

The Christian Church (Disciples of Christ) of Mid-America
Minister Information Form

This form allows you to provide the Mid-America Region with information for your clergy records. Should you have any questions, please contact your Ministry Associate in the Springfield Regional Office at sgf@ccmadisciples.org. Thank you so much!
Date:

MonthDayYear
Date
Title:
Name:

First NameMiddle NameLast Name
Preferred First Name:
Email Address:
example@example.com
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Gender
Please use this field at your own discretion.
Ethnicity
Please use this field at your own discretion.
Pronouns
Please use this field at your own discretion.

New or Current Place of Employment (Congregation or Ministerial Site):
The Name of your new or current Ministerial Site (Congregation/Organization/Institution). If you are Retired, please specify "N/A-Retired."
Address of New or Current Ministerial Site:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position at New or Current Ministerial Site:
Please provide your Position and Title. If you are Retired, please leave blank.
START DATE at New or Current Ministerial Site:

MonthDayYear
If you are Retired, please leave blank.
Previous Place of Employment (Congregation or Ministerial Site):
if applicable
Address of Previous Ministerial Site:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Ministerial Site Position & Title:
Begin Date for Previous Ministerial Site:

MonthDayYear
Date
End Date for Previous Ministerial Site:

MonthDayYear
Date
Are you Bi-Vocational or Co-Vocational?

Other
Secondary Employment: Position & Title
Secondary Employment: Name of Ministerial Site or Employer
Congregation, Organization, or Institution where you are also Employed or Ministering.
Secondary Employment: Begin Date
Are you Volunteering anywhere? (To better understand the full scope of your Ministry.)

Other
Position & Title as a Volunteer
Name of Organization where Volunteering
Begin Date for Volunteer Position
Comments or Additional Information (if applicable)
Anything else that you feel will be helpful for the Mid-America Region to know or for record-keeping purposes.
Additional Files or Documents (if applicable)

Please upload any additional files/documents that you would like stored in your Mid-America Regional clergy file.
Cancelof
Signature: The information contained in this form is true and accurate as best my memory serves me.
Should be Empty: