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NO. __________
DATE JOINED: ____________
FAMILY INDIVIDUAL
UPPER ROOM COGIC MEMBERSHIP PROFILE PERSONAL CONTACT INFORMATION Last Name:
First Name:
Marital Status: Single Married Is your spouse already a member?
Birth Date: ____/____/_____
Divorced Widow
Yes
Member Status: Watch Care
Full time
No
If yes, please list their full name (including maiden name) ________________________________________ If you were previously a member, please list any other name that you were referred to when you were a member: (Ex: nicknames, maiden name, former marriage name) __________________________________ Have you accepted Jesus Christ as your Personal Savior? Yes No When/what year did you accept him? ___________ Home Address: Home Phone #:
Have you been baptized?
Yes No
If no, would you be interested and would like to know more? Yes No City, State, Zip:
Mobile Phone #:
Employer:
Email: Work Phone #:
Member Identification Number (MIN): SPOUSE CONTACT INFORMATION Last Name:
First Name:
Have you accepted Jesus Christ as your Personal Savior? Yes No When/what year did you accept him? ___________ Home Phone #:
Mobile Phone #:
Employer:
Birth Date: ____/____/_____ Have you been baptized?
Yes No
If no, would you be interested and would like to know more? Yes No Email: Work Phone #:
Member Identification Number (MIN): CHILDREN CONTACT INFORMATION – Please list children names who are joining with you Full Name:
Birth Date: ____ /____ /____
MIN #:
Full Name:
Birth Date: ____ /____ /____
MIN #:
Full Name:
Birth Date: ____ /____ /____
MIN #:
Full Name:
Birth Date: ____ /____ /____
MIN #:
Revised 10/29/2015