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The Basics of Biblical Counseling - Biblicalcounselingonline.org

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For Office Use only<br />

Ck # ____________<br />

CkDate ____________<br />

Ck Amount _________<br />

Application for Membership<br />

(To be completed electronically and mailed to Certification@NANC.<strong>org</strong>)<br />

Personal:<br />

Title: First Name: Last Name:<br />

Address:<br />

Spouse:<br />

City: St: Zip: Home Phone:<br />

Daytime Phone:<br />

Employer:<br />

Position:<br />

Email Address:<br />

Birthday: Sex: Marital Status:<br />

Church You Attend:<br />

Are you a member?<br />

Are you ordained?<br />

If yes, by whom and when?<br />

Pastoral experience (dates and places):<br />

Education:<br />

College:<br />

Degree Year Major<br />

Seminary Degree Year Major<br />

Graduate School<br />

Degree Year Major<br />

Other pr<strong>of</strong>essional education or training:<br />

Pr<strong>of</strong>essional agencies or <strong>org</strong>anizations to which you belong:<br />

Revised 6/2010<br />

185

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