Please fill out the form below and click submit to include your information on the Church Planters' Needs List.  This list will be passed out to pastors each day of our conference.

Church Planter/Home Missionary's Name: 

Phone:    Email Address: 

Address:    Apt. No: 

City:   State:  Zip: 

Name of Starting Church:

Starting Church Address: 

City:    State:    Zip:    Phone: 

Sending Church:     Sending Pastor: 

Sending Church Address: 

City:    State:   Zip:    Phone: 

When did/will you start the church?  JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember    (ex:  2005)

How many other churches have you started? 

Do you plan to attend the Church Planting Conference (January 12-14, 2010)?    Yes      No
If yes, when will you arrive?  January  89101112131415

Are you currently working a secular job?    Yes       No

Are you currently receiving monthly support?     Yes      No
If yes, how much? 
Additional monthly support needed to pastor full-time? 

Church Property:    Own      Rent

Specific needs for church: 

Specific needs for yourself: 

Specific needs for your wife: 

Specific needs for your children: 

Please submit before January 4, 2010.