Clergy Registration Data Commission Application
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Personal Information are Secured & Confidential.
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| Name
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| Prefix
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| First
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| Last
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| Suffix
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| Birthdate
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| Home Address (please enter "SAME" on line 2 if no other address apply)
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| Street Address
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| Address Line 2
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| City
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| State / Province / Region
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| Postal / Zip Code
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| Country
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| Phone Number
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| Name & Church Address
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| Street Address
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| Address Line 2
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| City
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| State / Province / Region
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| Postal / Zip Code
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| Country
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| Church Phone Number
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| Your Title
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| Name of Apostle, Bishop, Pastor, or Overseer, ect.
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| Any current criminal involvement as it relates to the Ministry?
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Yes No
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| Name of Theology or Siminar School(s) Attended.
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| Date of Certificate or Degree
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MM/DD/YYYY
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| May We Contact Your Pastor?
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Yes No
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| Email
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I certify that the information contained in this application is true. I understand that falsifying any information on this application may cause forfeit of Licensure, and immediately termination out of CRDC database. At any point in the future, there's No Membership Refund.
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| Do you agree with the terms and conditions?
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Consent Form
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| Do you give consent to Clergy Registration Data Commission to release infomation concerning your license as an Ordained Clegy on our web-site.
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please click yes to complete the application, otherwise STOP here.
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| Please select all information release to Clergy Registration Data Commission web-site.
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| Initial
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| Today's Date
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| Upload Photo for I.D.
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ATTENTION: Please upload a clear "Face-Shot" that is free of objects in the face including hands, light, hair, clothing, etc. Any photo uploaded with following objects in face will cause a delay in the License process.
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Image Verification
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EMF Web Form