Clergy Registration Data Commission Application

Personal Information are Secured & Confidential.

Name *
Prefix
First *
Last *
Suffix
Birthdate *

MM
/
DD
/
YYYY
Home Address (please enter "SAME" on line 2 if no other address apply) *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Phone Number *

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Name & Church Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Church Phone Number *

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Your Title *
Name of Apostle, Bishop, Pastor, or Overseer, ect. *
Any current criminal involvement as it relates to the Ministry? *
 Yes 
 No 
Name of Theology or Siminar School(s) Attended.
Date of Certificate or Degree
MM/DD/YYYY
May We Contact Your Pastor? *
 Yes 
 No 
Email

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.

Do you agree with the terms and conditions? *

Consent Form

Do you give consent to Clergy Registration Data Commission to release infomation concerning your license as an Ordained Clegy on our web-site. *
please click yes to complete the application, otherwise STOP here.
Please select all information release to Clergy Registration Data Commission web-site. *
Initial *
Today's Date *

MM
/
DD
/
YYYY
Upload Photo for I.D. *
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.
Image Verification
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