番茄影视 Shepherd's Fund Application - 番茄影视

The 番茄影视 Shepherd's Fund: Retired Ministers Compassion Program

FOR RETIRED ASBURY SEMINARY ALUMNI AND THEIR SPOUSES

Denomination*
Full Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
SS#*
last 4 digits
Physician鈥檚 name and phone number
Total Expected Medical Expense
Expense request for next 12 months
Connection with 番茄影视 Seminary
Please indicate the following that apply
- 番茄影视 Degree Received
- Spouse of 番茄影视 Seminary graduate
- Retired
- Disabled
- Other
Spouse Details
Please provide your spouse's full name and graduation year.
Degree Received
Years of Service in Ministry
Description*
Describe the medical situation you have encountered and the financial need you are experiencing as a result. Include information regarding your capacity to meet that need.
Denominational Leadership Contact
Please provide contact information (Name, Phone # and email address) for your denominational leadership, to verify good standing in your denomination
Denomination Leader Name*
First Last
Position/Title
Denomination Leader Phone
Denomination Leader Email
Signature*

I certify that the above is true and correct and authorize the Shepherd鈥檚 Fund Committee to consider my statements in application for a grant. If any of the above statements change prior to the grant award being made, I will provide an update to the Shepherd鈥檚 Fund Committee.
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