Holy Light Pentecostal Ministries, Inc.

AFFILIATE-COVENANT MEMBER APPLICATION

(Headquarters) 33 South Clover Street, Poughkeepsie, New York 12601
IMPORTANT: FOLLOW THESE INSTRUCTIONS. Complete ALL sections. This information will be used to evaluate your qualifications.
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
How long have you resided at this address?
Phone - (###) - ### ####
Email(s)
Marital Status Single Married Divorced Widowed Separated
Are you a U.S. citizen?
Are you a permanent resident?
If neither, country of citizenship
Could you successfully pass a criminal background check?
Could you successfully pass a child abuse clearance?
Have you ever been convicted of a crime, other than a minor traffic violation?
If yes, please explain.
Name of Church
Affiliation
Church Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Church Phone - (###) - ### ####
Ministerial Classification
Are you incorporated?
If not, do you have a D.B.A. (Doing Business As) to be operating as a religious entity?
How long has your church/ministry been established?
Are you the founder/planter of the church, ministry, mission or organization?
How long have you been pastoring?
Are you licensed or ordained?
If yes, by whom?
How many members do you have?
How did you hear about HLPM?
Your desired relationship with HLPM: Mission Church Special Ministry Para-Church Organization/Institution
Why have you chosen to become an affiliate-covenant member of this ministry?
Have you ever resigned or been expelled by a church, denomination or other governing body?
If yes, please explain.
What gifts, talents or experience will you bring to this organization?
EDUCATIONAL HISTORY
High School
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
Business or Technical
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
College or University
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
College or University
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
Graduate School
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
U.S. Military Education
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
Other
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Major/Degree
CHECK THE HIGHEST GRADE COMPLETED:
High School 9 10 11 12
College 1 2 3 4
Graduate School 1 2 3 4
REFERENCES Please list (3) personal/professional references (non-related) who we can contact to give an honest and critical evaluation or commendation of you and your ministry:
1st Reference
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
2nd Reference
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
3rd Reference
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
PLEASE READ CAREFULLY: By my signature below, I affirm that I have read and understand this application and that I have not knowingly withheld any important information, fact or circumstance. I further understand that my membership acceptance is contingent upon reference checks and the truth of the statements made herein and in any interview. Any misrepresentation or omission may be cause for dismissal.
In consideration of my membership acceptance, I agree to conform to the rules and regulations of Holy Light Pentecostal Ministries, Inc. The persons, schools and other organizations named in this application are authorized by me to verify the information that may be requested by Holy Light Pentecostal Ministries, Inc. to arrive at a decision. I am willing that a photocopy of this authorization be accepted with the same authority as the original.
I hereby waive and release all persons, schools and other organizations from any liability arising from the disclosure of any of the above information whether in writing or orally. I further, waive and release Holy Light Pentecostal Ministries, Inc. from any liability arising from reliance of the aforementioned information or the use, publication, or retention of such information within the context of its application review procedures.
Electronic Signature
Date / MM / DD YYYY
After reading our Tenets of Faith and the Code of Ethics are you willing to obey and accept these tenets and codes as your profession of faith?
Electronic Signature
Date / MM / DD YYYY

Holy Light Pentecostal Ministries, Inc.

(Headquarters) 33 South Clover Street, Poughkeepsie, New York 12601

IMPORTANT: FOLLOW THESE INSTRUCTIONS. Complete ALL sections. This information will be used to evaluate your qualifications.

EDUCATIONAL HISTORY

CHECK THE HIGHEST GRADE COMPLETED:

REFERENCES Please list (3) personal/professional references (non-related) who we can contact to give an honest and critical evaluation or commendation of you and your ministry:

1st Reference

2nd Reference

3rd Reference