Name: First, Last

E-mail address

Mailing address

City, State, Zip

Phone (xxx)xxx-xxxx

Today's Date
(mm/dd/yyyy)

Select from the pop-down menu the option that best describes your status
--Click here to see selection menu-- *You may remove my name from the Grace roll since I have joined and am a member of another church. *Retain my membership for now; I am committed to joining another church within the next year. *Retain my membership for now; I am currently in process of joining another church; check back in a few months. *Retain my membership for now due to special circumstances which I will explain in the comments below (military, school, etc.) *You may remove my name from the Grace roll because I do not intend to join another church. *Other (explain in comments below)

Other comments - special notes:

If you have joined (become a member) of another church, please provide the church name and address.

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