Registered Chaplain Membership Renewal Form

Membership Renewal Form
Documents will be sent to the address you list below, please make sure you list the address where you want your documents to be sent.
Membership Renewal forms must be signed and mailed to the home office. They CANNOT be sent by fax or e-mail.

This application must be printed in Landscape format. Please type or print clearly

Name: ____________________________________________________ Date: ________________

Address: ________________________________________________________________________

City: ____________________________ State: _______________ Zip Code:__________________

Home Phone (____) _______________________ Business Phone (___)_____________________

E-mail Address: __________________________________________________________________

Hair Color: ____________ Eye Color: __________ Height: __________ Weight: ______________

I have been a member Since: Date: __________________________________________________

My member's ID Card Number is: ___________________________________________________

My membership expires or expired on: _______________________________________________

PLEASE NOTE: Emergency contact information and any major health problems you may have will be encoded in the magnetic strip on the back of your wallet ID Card. This has helped save one of our member's life involved in an auto accident.

In Case of an emergency notify: _______________________________________________________ Relationship: ____________________________________ Phone: _________________________________

Health Problems: Heart Disease: _______ High Blood Pressure: _________ Diabetes: ________ Other: ___________________________________________________________________________________

Chaplain Fellowship Ministries Holds all Members Accountable For Their Actions - Without Accountability There Is No Credibility

Have you ever been arrested or charged with a crime within the past twelve months? [ ] Yes [ ] No -If yes please explain on the back of the application. We are very understanding, many of us have been broken and have had our own problems. That is why most of us know what it means to say we walk the walk! No Application for renewal will be processed without all required information being completed. Make sure you read this carefully before signing. No application for renewal of membership, license or endorsement will be considered or processed without this application being completed in full, signed and dated.

[ ] I am submitting my $65.00 membership renewal for the stability and advancement of Chaplain Fellowship Ministries

[ ] I am submitting my $65.00 membership renewal and a monthly pledging of: [ ] $10.00 [ ] $15.00 [ ] $20.00 [ ] $25.00 [ ] $30.00 [ ] $35.00 [ ] $45.00 [ ] $55.00 [ ] $100.00 [ ] $200.00 [ ] $300.00 [ ] $400.00 for the stability and advancement of Chaplain Fellowship Ministries.

[ ] I am submitting my $65.00 membership renewal and a one time donation of: [ ] $10.00 [ ] $15.00 [ ] $20.00 [ ] $25.00 [ ] $30.00 [ ] $35.00 [ ] $45.00 [ ] $55.00 [ ] $100.00 [ ] $200.00 [ ] $300.00 [ ] $400.00 for the stability and advancement of Chaplain Fellowship Ministries.

1. I hereby certify that the above information is true to the best of my knowledge. I understand that Chaplain Fellowship Ministries will be relying upon this information to grant me approval regarding my membership renewal. I acknowledge that any false information provided by me will be just cause to deny renewal of my membership. Should any of my personal information or responses to these statements change I will immediately notify the home office of Chaplain Fellowship Ministries within 14 working days. I understand that my membership with Chaplain Fellowship Ministries does not give me the rights to state or federal tax exemption.

Signature Required: _____________________________________________________ (REQUIRED)

Checks or Money Orders: All donations must be in US funds. Make payable to: Chaplain Fellowship Ministries, Mail your completed renewal application with your check or money order to the address listed below. Renewal membership packages may take up to 2 to 3 weeks for delivery once received in our office.

Major credit cards are accepted: You can make your donation using your major credit card by clicking on the add to cart button below. There will be $3.00 dollars added to your credit card to cover PayPal charges. Mail your completed application to the address at the top of this application after making your donation. Renewal membership packages may take up to 2 to 3 weeks for delivery once received in our office.

Please Note: Unscriptural conduct or failure to maintain membership requirements in good standing or doctrinal departure from the tenets of faith shall be considered sufficient Grounds upon which any person may be disqualified and removed from membership. The requirements and information required within this application shall be subject to change without notice. The board of directors does hereby have the right to refuse membership renewal for Unscriptural conduct or failure to maintain membership requirements in good standing. All decisions made by the board of directors are final and binding. No goods or services were provided for donations other than intangible religious benefits.