Your full name:

Address:

Telephone No: Office

Fax No: Office

Telephone No: Res

Fax No: Res

Give contact details of your Pastor. If you are the pastor, give another reference Pastor's name:

Denomination:

Address:

Phone:

E-mail:

The goals or purpose of ministry you are involved in:

If you know any aicc staff or leaders, please give their name(s):

In a few words, explain why you want to join aicc?