I live in Northern California (north of Fresno) or Nevada and am interested in getting credentials with the Assemblies of God Northern California & Nevada District Council. * - Select -YesNo Contact your local district. First Name * Middle Initial Last Name * Email * Cell Phone * Address * Address 1 Address 2 Address 2 City * State * Zip * Background Information Date Baptized in water by immersion * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Date Baptized in the Holy Spirit with Initial Evidence of Speaking in Tongues * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year College / University * Degree Major * Number of Berean Courses Completed * - Select -0123456789101112131415161718192021222324252627282930 Marital Status * - Select -SingleMarriedDivorcedWidowed Have you ever been divorced? * - Select -YesNoN/A Is former spouse still living? * - Select -YesNoN/A Has your spouse ever been divorced? * - Select -YesNoN/A Is spouses former spouse still living? * - Select -YesNoN/A Current Ministry Involvement * Status - None -US CitizenGreen CardRI VisaOther If other status, please explain * Comments * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 9 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.