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Church Planter Preliminary Assessment

Step 1: Please provide the following information about yourself including either a domestic or international address. (Note that "" indicates a required field.)**

Title:	**First name:	**Last name:

Address line 1:	Address line 2:

City:	State:	Zip code:


International addresses may be entered in the space below:


**Home phone:	Office phone:	**I prefer to be contacted at:
		Home Office
**The best time of day to reach me at my preferred location is:
Morning Afternoon Evening Anytime


**E-mail address:	**Confirm e-mail address:


In preparation for church planting, I have done the following (check any that apply):
Read books and articles on church planting. Attended a class on church planting. Attended a workshop on church planting. Undergone an assessment as a church planter. Attended a church planting training program (boot camp).

Please tell us (in 60 words or less**) why you want to plant a new church.


Please tell us (in 90 words or less**) about a new group you have formed for any purpose.




Please enter the characters shown above:
(Entering this code improves security for the transmission of your data.)