APPLICATION FOR MISSIONS MINISTRY

Name Mission to: PERU, SOUTH AMERICA

Print Name EXACTLY As It Appears On Your Passport

Address Date: Thurs., Aug. 5th – Sun., Aug. 15th, 2010

City State Zip Optional PreTrip: Sun., Aug. 1st – Thurs., Aug. 5th, 2010
to Cuzco and Machu Picchu, Peru
Home Phone: ( )
Participating in PreTrip? YES or NO
Cell Phone: ( ) Circle One

E-Mail Address:

Occupation: Passport Number:

Birthdate: Date Issued:

Married or Single Expiration Date:

Circle One
Spouse’s Name Frequent Flyer Program:

Frequent Flyer Number:

Please sign your name EXACTLY as it appears on your Passport:

A DEPOSIT of $200. MUST BE INCLUDED WITH THIS APPLICATION. Please do not send in
application without deposit. Your space will not be reserved until your deposit is received! Your $200.
deposit will be applied to your ticket.

MAKE CHECK PAYABLE to Breiel Blvd. First Church of God

Mail Check and Application to: Breiel Blvd. First Church of God
2000 North Breiel Blvd.
Roma Lee
Courvisier
Middletown, OH 45042
with a
child
(513) 424-1887
named
after her
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bbeeyyoonnddtthheeiirraabbiilliittyy…
…SSeeee tthhaattyyoouuaallssooeexxcceelliinntthhiissggrraacceeooff
ggiivviinngg…
…YYoouurrpplleennttyyw wiilll ssuuppppllyyw
whhaatttthheeyy nneeeedd””
--IIIICCoorriinntthhiiaannss88::33,, 77,,1144