Cell Group Leader's License Application

Contact Information

Name*

First Middle Last Suffix

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Previous Address (A)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long?*

Previous Address (B)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long?

Previous Address (C)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long?

How did you learn about ICCM?*

How?*

ICCM Director's name?*

Are you a faithful and consistent tither to your Church?*

If no, provide a detailed explanation below as to why, as a non-tither, you should be considered for this high position.*

Personal Information

Are you a U.S. Citizen?*

Social Security Number*

Gender*

Driver's License Number*

State*

Marital Status*

Name of Spouse*

Number of Children*

When?*

Conditions under which divorce was granted:*

Reason*

Church Information

What Church do you attend?*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you been a member?*

Is your Pastor aware you are filing for Cell Group Leader License?*

If no, what are your reasons for applying for this license?*

Will you agree to sign our Non-Compete and Non-Disparaging Agreement to protect your Pastor and your Church?*

Application Acceptance Agreement

I hereby declare that each of my statements given or made in this application and any supporting documents are correct and true; I solemnly pledge to abide by all promises and statements contained therein.

Application Signature*

Date Signed*

Pastor's Endorsement

I hereby consent for the above Member of my Church to receive their Cell Group Leader's License. I understand they will be required to sign a Non-Compete and Non-Disparaging Agreement to protect my Church and me from splits and divisions.

Senior Pastor's Signature*

Cell Number*

Date Signed*

Payment Information

License Application Fee

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Cell Group Leader’s License Application