Apply For Membership

Send Application To:
Potter's House Pastoral Alliance
6777 West Kiest Boulevard
Dallas, Texas 75236

Important Information for All Members

To activate your membership in the Potter's House International Pastoral Alliance, complete this form, print the page and mail it to the address listed above. Please include a copy of your church's vision and mission statement, and the first contribution of your monthly tithes and/or offerings made "Pay to the order of PHIPA".

Name Title
Spouse's Name    
Organization    
Street Address    
Address (cont.) City
State Zip/Postal Code
    Country
Work Phone Home Phone
FAX E-mail
Web site / URL    
    • Pastor's Birthday        -- mm/dd/yy
    • Spouse's birthday        -- mm/dd/yy
    • Pastor's Anniversary    -- mm/dd/yy
    • Wedding Anniversary    -- mm/dd/yy
    • Years church has been in existence   
    • Size of church membership   
    • Number of Church Staff       
    • How many in Leadership       
    • Denominational Affiliation       
    • Church Tax Exemption    Yes No

  • Please list all active church outreaches/ministries and auxiliaries:
    (Use Separate Sheet to list.)

  • Contact Person/Secretary

    Name
    Title
    Work Phone
    FAX

    E-mail
  • Office Hours   
    		•