What is the NAME of your ministry for which funding may be directed?

Ministry Name:

Personal Administrator

(Handles your ministry affairs here at home)

Name

Address

City, State, Zip

Phone (including area code)

(               )                -

E-mail

Backup Personal Administrator (optional)

Name

Address

City, State, Zip

Phone (including area code)

(               )                -

E-mail

Emergency Contact

Name

Address

City, State, Zip

Phone (including area code)

(               )                -

E-mail

Power of Attorney

Who of the above has Legal Power of Attorney for you in your absence?

Name

Financial and Prayer Supporters

Please attach to this sheet a list of all names, addresses, phone numbers, and E-mails for your support team members whom you wish entered into our database.

(Form updated 10/28/2001)