Name *

First Name

Last Name

Mobile Phone

(###)

###

####

Home Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday

MM

DD

YYYY

Gender

Male

Female

Marital Status

Single

Married

Separated

Divorced

Widowed

Salvation

Have you accepted Jesus Christ as your Savior and repented of your sins?

Yes

No

Baptism

Have you ever been baptized by complete submersion in water?

Yes

No

Membership

I want to become an E-Church member of Fitzgerald Church of God.

I have some questions before I make a decision about becoming a member.