First Name

Last Name

Street Address

City

State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip


Mailing Adress (if Different)

City

State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip

Daytime Phone

Evening Phone

Cell Phone

E-Mail

(A copy of your valid driver’s license and proof of insurance must be brought with you if you are accepted.)

Married
Single
Seperated
Divorced
Widowed

If married, what is your spouses name?

Age of your spouse: Number of years married:

Number of children living with you:

Please list the names and ages of the children:

How did you hear about Auto Care Ministry?:

Are you currently employed?
Yes No

If yes, please tell us where.


If you are not employed, please tell us how long you have been unemployed:

Last place of employment:

Is the Church of the Nazarene your home church?
Yes No Undecided

Name of church:

Are you a member?
Yes No Undecided

How often do you attend church services?
More than once a week More than once a month More than once a year

Are you sure you will go to Heaven when you die?
Yes No Not sure What do you mean?

Why or why not?


What prayer needs do you have this week?

Select Year... 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986

Select Make Acura Audi BMW Buick Cadillac Chevrolet Dodge Ford Honda Hyundai Isuzu Jaguar Jeep Land Rover Lincoln Mazda Mercedes Benz Mercury Mitsubishi Nissan Oldsmobile Plymouth Pontiac Saab Saturn Subaru Toyota Volkswagon Volvo

Motor Size 3 Cylinder 4 Cylinder 6 Cylinder 8 Cylinder Don't Know

Please explain in as much detail as you can the problem(s) that which are occuring.