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Last Name / Nom de famille

First Name / Prénom

Select Gender / Sélectionnez le sexe

BirthDate / Date de naissance

Address

City

State

ZipCode

Cell Phone / Téléphone

Select Marital Status / Sélectionnez l'état matrimonial

MarriedDate

Spouse Name / Nom du conjoint

Have you accepted Jesus Christ?

Yes

Date of Salvation (if known):

Have you been baptized?

Yes

Date of Baptism (if known):

Previous Church Name

Reason for leaving previous church

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