2nd Year Registration (Part 2)

General Information

Date:

Name:

Social Security #:

Date of Birth:

Address:

City:

State:

Zip/Postal Code:

Phone:

Fax:

Email:
Permanent, if other than above:

Address:

City:

State:

Zip/Postal Code:

Phone:

Fax:

Email:

Education and MInistry Experience:

(You may attach a resumé that covers the below information)

List all schools attended since high school:
School Location Years Attended Degree/Specialty
Church/Service/Ministry Experience:
Position Church/Organization Location Dates Resposibilities

Faith Affiliations

Home Church:

Address:

City:

State:

Zip/Postal Code:

Phone:

Pastor:

Phone:

Denominational Affiliation:

Security:

Have you used any names or Social Security Numbers other than those on this page?
Yes No
If so, please list:




Have you been convicted of, or served time for a felony in the past seven years?
Yes No
If so, please describe:

Certification and Release:

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my time in Miami. I authorize DOOR and/or its agents, including consumer-reporting bureaus, to verify any of my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs and/or alcohol, or possession of weapons is strictly prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during placement.



Signature:___________________________________________________


Date:_______________________

print page

(If the print button does not work with your browser, print the page through your browser button or your Menu Selection "File" - "Print")