Minister’s Benevolence Fund Application
Your Information
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Are you...
*
Licensed
Ordained
What district?
*
Please Select
North Alabama
South Alabama
North Georgia
Central Georgia
Florida
West Carolina
East Carolina
Virginia
New Horizons
What year did you become a Minister with the Congregational Holiness Church?
*
Please enter numbers only.
Do you have a spouse?
*
Yes
No
Spouse Information
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
Are you licensed with the Congregational Holiness Church?
*
No
Yes
Are you...
*
Licensed
Ordained
What district?
*
Please Select
North Alabama
South Alabama
North Georgia
Central Georgia
Florida
West Carolina
East Carolina
Virginia
New Horizons
Executor & Beneficiaries Informations
Do you have an executor of your estate?
*
Yes
No
Is the executor also a beneficiary?
*
Yes
No
Executor Name
*
First Name
Last Name
Executor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Address of Executor
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Beneficiaries in Case of No Spouse (DO NOT INCLUDE EXECUTOR)
*
Family Contacts (Other Than Children) - In Case of Emergency
*
Would you like to pre pay for any activations?
Yes
No
How much would you like to prepay?
Application Fee
Credit Card Fee
Total
Total
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next
( X )
USD
Description
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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