1. Mindat Christian Fellowships /Church
Member’s Information
Last Name ________________ FirstName ________________ Date of Birth ______________ Date of Membership
Spouse’s LastName ________ Spouse’s FirstName ________ Spouse’s Date of Birth _______ Date of Membership
Street Address
City ____________________________ State _____________________________ Zip Code _____________________
Phone: Work ______________________ Home _____________________________ Mobile/Other _________________
Date of Born again __________________________ Email Address ___________________________________
Dependents (Living In Your Home)
1. FirstName _______________________ Last Name (if different from above) _________________
Date of Birth _______________________ Date of Membership ________________ Male or Female ________________
2. FirstName _______________________ Last Name (if different from above) ________________
Date of Birth _______________________ Date of Membership ________________ Male or Female ________________
3. FirstName ______________________ Last Name (if different from above) ________________
Date of Birth ______________________ Date of Membership ________________ Male or Female ________________
4. FirstName ______________________ Last Name (if different from above) ________________
Date of Birth ______________________ Date of Membership _________________ Male or Female ________________
5. FirstName ______________________ Last Name (if different from above) _______________
Date of Birth _______________________ Date of Membership _________________ Male or Female ________________
Please Note: We have to update members every 2-6 months to keep our records up to date. Your mobile and work phone will not be
included in the MCF Directory, but will ONLY be used for emergency purposes such as a MCF service cancellation. Thank you for
your patience. Please turn your application back in to the MCF Secretary when you are finished. Thank You. God Bless You.
