Licensed Lay Ministry Application
Today's Date
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Month
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Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
Name of Your Congregation or Ministry Site
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Address of Your Congregation or Ministry Site
*
Phone Number of Your Congregation or Ministry Site
*
Email Address of Your Congregation or Ministry Site
*
Mission District of Congregation or Ministry Site (Go to https://nepasynod.org/mission-districts/ to find your Mission District)
*
Please Select
Bethlehem/Easton
East Berks
West Berks
Hazleton/Lehighton
Lehigh
Northern Lehigh Valley
Pocono
Schuylkill
Scranton/Wilkes-Barre
Name of Current Pastor (Or Acting LLM/SALM), Type "None" if you do not have a pastor or acting LLM/SALM
*
Is This Pastor (Or Acting LLM/SALM):
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Permanent
Interim
Stated Pastor
Supply
No Pastor
If you have no pastor, please explain the congregation's situation.
How many years have you been a member of this congregation or ministry site?
*
Are you interested in being a LLM as part of a 6261 Ministry Community?
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Yes
No
Maybe
Employer Name
*
Employer Address
*
Employer Phone Number
*
Employer Email
*
How long have you worked for this employer? How many hours per week do you work? Please share your employment plans while you participate in the LLM formation path.
*
May we contact your Employer as a reference?
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Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
Why are you interested in becoming a Licensed Lay Minister?
*
Please share any food allergies, mobility concerns, or other information we should know when scheduling retreats, meals, etc.
Is there anything else you would like us to know or to take into consideration?
Signature
*
Please verify that you are human
*
Continue
Continue
Should be Empty: