"*" indicates required fields Name:* First Last Date of Birth:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Work Phone:Mobile Phone:Email:* I am a:* Layperson (Non-ordained or retired ministry staff is considered laity.) Minister (Active ordained ministers or other ministry staff.) Please write a brief personal salvation testimony.*Church Membership (Name of Church):*Church City and State:*Church’s Cooperative Program Contributions Last Year (Amount):*Church’s Cooperative Program Contributions Last Year (Percentage):*Do you personally support and/or financially contribute to your local church and consequently the work of the Missouri Baptist Convention and Southern Baptist Convention through the Cooperative Program?* Yes No List positions served and offices held in the local church, association, or MBC/SBC boards, committees, commissions, or institutions.*Occupation:*Employed by:*Give a brief statement of unique business/professional experience that might be beneficial to the entity or commission you would serve.*Will you read, agree with, and affirm the Baptist Faith and Message (current edition) for the duration of your term as a trustee for the MBC?*(For a copy of the Baptist Faith and Message click here.) Yes No ReferencesPlease give two references familiar with your local church involvement and your lifestyle — one that demonstrates a decorum of holiness consistent with New Testament character, including the abstention from recreational use of controlled substances (including alcohol and marijuana). Name, Address, and Phone Number for Reference #1:* First Last * Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference #1 Phone:*Reference #1 Email: Name, Address, and Phone Number of Reference #2:* First Last * Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reference #2 Phone:*Reference #2 Email: I pledge to complete the MBC new trustee orientation, as well as the orientation of the entity or commission where I may be nominated to serve.* Yes No Once elected to your position, would you, if requested, agree to a background check by the Missouri Baptist Convention or the entity you are nominated to serve?* Yes No Subject to election by the MBC at the Annual Meeting, I would like to serve on (choose all that apply):* MBC Executive Board Missouri Baptist Children’s Home Hannibal-LaGrange University Missouri Baptist University Southwest Baptist University Missouri Baptist Foundation Missouri Baptist Historical Commission Christian Life Commission The Baptist Home Credentials Committee Committee on Order of Business
