Application for Membership

Organization Name ________________________________________________________

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Contact Names/Titles ______________________________________________________

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Address ________________________________________________________________

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Home Phone __________________________ Cell Phone __________________________

Email ___________________________________________________________________

List any memberships or affiliations with any spiritual organizations here or on the back of this application.

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Signature _____________________________________ Date ____________

Please send your check or money order to:

FSHLB License Commission
8417 Oswego Road #131
Bldwinsville, NY 13027

Contact us at: spiritualicense @ gmail.com (no spaces)