Date:

Name:

Wife's Name:

Do you have any children that will be coming with you?

If so, how many?

Home Address:

Home Phone:

Cell Phone:

E-mail Address:

Requested Arrival Date:

Departure Date:

Reason for Coming: Please check one of the following:  Crisis (     )     Time off (     )

Home Church:

Address:

Church Phone:

Have you visited Shechem before?  Yes (     )      No (     )

If yes, when?

If you prefer to send the application through regular mail, please submit a completed application to the following:   Corinth Christian Church ATTN:  Shechem Ministries 1011 Corinth Road Lawrenceburg, Kentucky  40342   Gene Koons, Minister 502-839-6116 - Church office 502-859-5424 - Home

APPLICATION E-MAIL