Potential Planter's Application for New Church Start Discernment Process

*First Name
*Last Name
*Preferred Name
*Address 1
Address 2
*City
*State
*Zip
*Phone
*Email
*Indicate whether the phone number listed above is home, office, or cell.
Home
Office
Cell
FAX Number

Please include area code.

*Is the address listed above your home address or office address?
Home Address
Church/Office Address
*Your Current Appointment

Name of Church, Extension Ministry, Leave, or Retired

*In what county is your church located?
*District
*Your Clergy Status Code

Reflecting your relationship with the Kentucky Annual Conference.

Family Status
*Marital Status
Spouse's Name
*Do You Have Children?
Yes
No
Please Enter Each Child's Name and Age in the Space Below
*Your Health
Health Status
Spouse's Health
Child(ren)'s Health

Child 1

Child(ren)'s Health

Child 2

Child(ren)'s Health

Child 3

Child(ren)'s Health

Child 4

If you have more than 4 children, please list all others with their Health Status below

Using the choices of Excellent, Good, Fair or Poor.

*Describe Any Limiting Factors

For yourself

Describe Any Limiting Factors

For your spouse

Describe Any Limiting Factors

For your child(ren)

Education
*College
Yes
No
Major
Years Attended
Degree
*Seminary
Yes
No
Major
Years Attended
Degree
*Graduate School
Yes
No
Major
Years Attended
Degree
*Other
Yes
No
Major
Years Attended
Degree
*Ordination
Yes
No
Date of Ordination
Explain Your Current Church Status
Previous Church Experience
*Title
*Church
*City & State
*District
*Dates

Include Begining Date as well as Ending Date.

Comments
If You Are Currently Pastoring a Church, Provide the Following:
Present Base Salary

Enter amount per year.

Parsonage

Enter amount per year.

Health Insurance

Enter amount per year.

Professional Allowance

Enter amount per year.

Utilities Allowance

Enter amount per year.

Other

Enter amount per year.

For the Past Five Years (or as long as you have served there):
*Membership

Current Year

Only number values are allowed
*Worship

Current Year

Only number values are allowed
*Sunday School Attendance or Small Group Participants

Current Year

Only number values are allowed
*Apportionment %

Current Year

Only number values are allowed

___________________________________________________________________________________________________________________________________________________

*Membership

1 Year Ago

Only number values are allowed
*Worship

1 Year Ago

Only number values are allowed
*Sunday School Attendance or Small Group Participants

1 Year Ago

Only number values are allowed
*Apportionment %

1 Year Ago

Only number values are allowed

___________________________________________________________________________________________________________________________________________________

*Membership

2 Years Ago

Only number values are allowed
*Worship

2 Years Ago

Only number values are allowed
*Sunday School Attendance or Small Group Participants

2 Years Ago

Only number values are allowed
*Apportionment %

2 Years Ago

Only number values are allowed

___________________________________________________________________________________________________________________________________________________

*Membership

3 Years Ago

Only number values are allowed
*Worship

3 Years Ago

Only number values are allowed
*Sunday School Attendance or Small Group Participants

3 Years Ago

Only number values are allowed
*Apportionment %

3 Years Ago

Only number values are allowed
*Membership

4 Years Ago

Only number values are allowed

___________________________________________________________________________________________________________________________________________________

*Worship

4 Years Ago

Only number values are allowed
*Sunday School Attendance or Small Group Participants

4 Years Ago

Only number values are allowed
*Apportionment %

4 Years Ago

Only number values are allowed
Vision Statement
What is Your Church's Current Vision Statement?

Please type it in the box below or use the "Attach File" button below to upload your document.

What is Your Church's Current Vision Statement?

You may type your response in the box above or use this button to upload your files.

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

References
Please Include 2 References From Clergy and 2 References From Laity

Use this button to upload your files.

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

Authorization
By checking this box, you are authorizing The Kentucky Annual Conference or its authorized agents to conduct a credit/history and a criminal background check as a part of the application process.
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