MT – MR (formerly SOM) AND REENTRY REFERENCE FORM
*Please Note: TWO reference forms need to be printed and signed for each applicant—they must be signed by hand! An E-mail version of this form is unacceptable. Your application will NOT be processed without personal references.

RETURN FORM NO LATER THAN APRIL 1, 2008
ISMK
Assemblies of God World Missions
1445 N. Boonville Ave.
Springfield, MO 65802
Phone: 417-862-2781, Ext. 2390
Fax: 417-869-6280

Applicant’s Name: ________________________________

Because of the large number of applications, it is impossible to do background checks on each applicant. As a result, great reliance is placed on the representation of each applicant’s senior pastor, other pastoral staff, church board member, or area director that there are no facts or allegations that raise any questions concerning an applicant’s suitability for working with minors. Please have your senior pastor, a member of the pastoral staff, a church board member, an AGWM area director, an AGWM appointed missionary, or your employer complete the following certification. Choose the one who knows you best. DO NOT USE someone who is related to you, Chad Phillips, or any of the MK Office staff.

Please select one of the following:

• I am personally acquainted with the application, and in my opinion, he or she is competent and qualified to work with minors of any age. I know of no facts or allegations that raise any questions concerning his or her suitability for working with minors in any activity.
• I prefer to discuss my response by telephone. I can be reached at the following telephone number during the day:

Reference Name (Please print): __________________________________

Reference Signature: ___________________________________________

I am:

Go To Application
(Available January 1)