SWMC Mission Funding Application

PERSONAL INFORMATION

Your First Name(*)
Please let us know your name.

Your Last Name(*)
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Your Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Home Phone
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Cell Phone(*)
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Your Email(*)
Please let us know your email address.

Date of Birth(*)
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Gender(*)
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Name of Spouse
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Give a short discription of your
connection with Southwestern Medical Clinic
or how you heard of our funding program.
Please let us know your message.

 

PASTORAL INFORMATION

Name and address of your church and pastor
Please let us know your message.

SPIRITUAL INFORMATION

Please tell us about your relationship with God
Please let us know your message.

PROPOSED MEDICAL MISSIONS WORK

Name of Hospital or Location
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Address
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Name of affiliated church or missions organization
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Intended dates of service
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Identify the goals of your porposed mission trip
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Identify the specific expenses for which you are seeking funding
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Please list any individuals that may have referred you to SWMC for assistance.
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CERTIFICATION

I certify that the information in and attached to this application is accurate to the best of my knowledge and agree to the terms and conditions of the fellowship as described in the application.
Signed (Type Name)
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Today's Date
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