(Please
Print Clearly)
LEGAL NAME:
AKA:
NAME AS IT
SHOULD APPEAR ON B. DIV. CERT.:
ADDRESS & ZIP:
PHONE
(H):
(W)
FAX:
EMAIL:
BIRTH
DATE:
COUNTRY OF BIRTH:
NAME OF SPOUSE OR "SIGNIFICANT
OTHER":
PERSON (not living at your address) WHO
WILL ALWAYS KNOW
HOW TO CONTACT YOU:
their address with zip:
their phone: ( )
WHO TOLD YOU ABOUT UB?
MINISTERIAL FOCUS AND NAME:
DO YOU PRESENT WORKSHOPS/SEMINARS? YES
NO
(attach information if yes)
Do you grant permission to share your contact information with Universal Brotherhood University? YES NO
Do you grant permission to share your contact information with other UBM members? YES NO
Do you grant permission to share your contact information with others seeking any services you may provide? YES NO
"I Request Ordination into
Universal Brotherhood Movement, Inc."
Signed:__________________________________
(For Minister/Director only)
NOTES AND REMARKS: |
