Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Phone Number

(###)

###

####

Phone Number to List in KO Directory

(###)

###

####

Status

I hold Full Standing in the Conference.

I have questions regarding my standing.

Ministry Setting Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Service Began

MM

DD

YYYY

Second Ministry Setting Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Service Began

MM

DD

YYYY

Third Ministry Setting Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Service Began

MM

DD

YYYY

Date Authorized in the UCC

MM

DD

YYYY

Maintaining Covenantal Relationship

How have you maintained your covenantal relationship with the United Church of Christ during the past year? Please check all that apply.

Attended the annual meeting of my Conference

Participated in OCWM and other special offerings of the UCC

Served on a Conference/national UCC committee or board

Other (describe below)

Please check any of the following that apply to you

I have a plan for retiring from active ministry

I would like to be part of a ministerial group/community of practice

I already participate in a ministerial group/community of practice

I would like time for conversation with my Committee on Ministry and/or Conference Minister

Date Signed *

MM

DD

YYYY