International Christian Community Churches, Inc.

Annual Clergy Reporting Form

Please send this form along with a check or money order made payable to ICCC in the
amount of $50 (US) no later than December 31 to Rev. Emily Bel, BoM Chair, PO Box 8042,
Columbus GA 31908.

Name:
Address:
Home Phone Cell Work
E-mail:
Church: Position:
Year credentialed/ordained in ICCC: or Installed as Lay Pastor:
If your primary ministry is NOT in the above church, please indicate type and location of
ministry here:

Documentation of Continuing Education

Date Event/Training Sponsor Contact Hours

If approved by BoM for independent study, please indicate here and attach documentation as
requested by the BoM.

I hereby certify that I have not been charged with nor convicted of any criminal offense
during this reporting period.
I hereby certify that the information provided in this report is true and accurate.

______________________________________________ _____________________
Signature Date

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ICCC Pastors’ Manual 04.2007 Page 1