Name:   

Marital Status: Single Married Seperated Divorced Widowed

Occupation:         

Birthday: (mm/dd/year)

E-mail:

Phone:

Address:

City:   

State:

Are you a Christian? No Yes

What is your religious affiliation? None Christian Baptist Regular Baptist Methodist Wesleyan Nazerene Church of Christ Church of Christian in Christian Union Other Different Religion

Have you heard about Columbus First before? Yes No

If you have heard about Columbus First how did they heard about it? Other TV Newpaper Phone Book Friend Invite Flyer

Do you have have a need to pray about? None Salvation Sanctification Healing Rededication

How did you prefer to be contacted? E-mail Letter Phone Work Visit

Would you like a contact from the pastor? Yes No

Any other comments and information about this yourself?