Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Spouse's Name

First Name

Last Name

Spouse's Birthdate

MM

DD

YYYY

Are you willing to cooperate with the Georgia District By-Laws and North American Missions Policy? *

Yes

No

Have you discussed your plans with your pastor?

Yes

No

Does your pastor approve of your plans?

Yes

No

Unsure

Present or Former Pastor's Name

First Name

Last Name

Phone

(###)

###

####

District Superintendent's Name

First Name

Last Name

Phone

(###)

###

####

District Secretary's Name

First Name

Last Name

Phone

(###)

###

####

Sectional Presbyter's Name

First Name

Last Name

Phone

(###)

###

####

Employer's Name

First Name

Last Name

Phone

(###)

###

####

Affirmation *

I do hereby certify that I have carefully read the foregoing North American Missions policy, also the District By-Laws, and that I am wholehearedly in favor of the principles and policy of the United Pentecostal Church, as set forth in the Constitution and By-Laws of the organization and district. I further certify that by the grace of God, I shall do mybestto live up to the high standard as set forth in the ByLaws and the Constitution of the United Pentecostal Church: Further, that I will preach and teach only those doctrines which the organization endorses. I shall work in peace and harmony with all ministers and cooperate with all efforts of the organization. Inasmuch as our Lord and Savior, Jesus Christ, suffered, bled and died for our sins, I am willing to suffer for His Name and shall consider it a privilege to endure hardship and self-denial, for His sake and alost world, whenever the call ofservice demands it. I shall live dependent on God, receiving thankfully such support, as the North American Missions Department is able to supply, knowing that the Lord shall supply all our needs. I am going to the field with one supreme purpose, to glorify Christ, to win souls for Him and to hasten His coming.

I agree

Spouse agrees

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check either option 1 or option 2

Add the date of action taken below.

At a business session of the church a resolution was passed to adopt the Articles of Faith and by-laws of the United Pentecostal Church International. We now desire to work in cooperation with them and be under their protection.

This church was established by a minister of the United Pentecostal Church International and was set in order by a member of the District Board.

Date resolution passed

Or when church was established.

MM

DD

YYYY

We have adopted the suggested form of Local Church Government as in the current issue of the Manual and as it shall be amended from time to time.

Yes

No

Pastor *

First Name

Last Name

Secretary *

First Name

Last Name

Board Member

First Name

Last Name

Trustee

First Name

Last Name

Church Status Reporting *

Select one option and then complete the required fields below.

Existing church joining the UPCI (complete section 1)

Newly Formed Church (complete section 1)

New Daughter Work (complete sections 1 & 2)

Daughter Work becoming Autonomous (complete sections 1 & 2)

Date Established

MM

DD

YYYY

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pastor Name

First Name

Last Name

Mother Church Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother Church Pastor's Name

First Name

Last Name

Listing Options for the Directory

Select one.

List the name of the pastor of the Mother Church only.

List the name of the pastor of the Daughter Work only (Must be licensed with the UPC to be listed in directory).

List both the name of the pastor of the Mother Church & Daughter Work