SE District Lay Member At Large Application

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ethnic Background*

Gender*

Age Range*

Name of Local Church*

Position(s) in my local church:

Position(s) on the District level:

Position(s) on the Conference level:

YesNo

If yes, please list the year(s) you served as an At Large Lay Member:

If yes, what did you learn/contribute?

YesNo

If yes, please list year(s) you were a delegate to General Conference:

YesNo

If yes, please list year(s) you were a delegate to Jurisdictional Conference:

YesNo

Leadership UMC 1 Date:

Leadership UMC 2 Date:

Please list other leadership, ministry trainings, and laity certifications here:

YesNo

If yes, what year(s) were you a Teller?

YesNo

DELEGATE COVENANT: I am committed to remain with and support the UMC. I am committed to support my
local church, my District, and the North Georgia Conference through my prayers, presence, gifts, service,
witness and unity. If selected, I hereby agree to attend ALL sessions of the NGUMC Annual Conference (May
31 - June 2, 2023), and to prepare myself by attending the pre-conference briefing when scheduled. I
understand that the goal is to fully represent my District in all sessions. I further understand that maximum
reimbursement for expenses incurred during my attendance at the Annual Conference will be $300. I agree to
notify the District Office immediately, if circumstances will not allow me to fulfill this commitment, so that
another delegate can be selected.

Signature*

Lay Member At Large Application

Leadership Experience

Lay Member at Large Experience

Delegate Experience

Lay Servant Ministries Classes & Courses

Lay Servant/Speaker Info

Leadership UMC

Other Training/Certifications

Teller

Commitment to UMC