Name:___________________________________ Referred By:_______________________________

Address: ____________________________________________________________________________

City: _______________________________ State: ______________________ Zip: ________________

Email: __________________________________________________________ (Unique Per Member)

Phone (Primary):_________________________________ Other: _________________________________

Oak Chapter/Group Name: ____________________________________________________________

Oak Leader Name: ____________________________________________________________________

Church/Ministry Name: _______________________________________________________________

Ordained Minister (y/n) _____________________Ordaining Organization: __________________

Are you Interested in being a leader with The Oak?

Briefly describe how you can participate in and provide leadership with

The Oak Initiative: ___________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you already mobilized your neighborhood, church, business, city etc.?

If so, please explain: ________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please select payment method for your per person membership donation:

[   ]  Check           [   ]  Cash          [   ] Credit Card                 Credit Card Type: _______________________

Credit Card Number: ________________________________________ Exp.: ___________/_________

CVV Code (3-digit, back of card): __________________

Donation Amount: $________________________________________

Signature: ______________________________________________________________________________

Note: Please send one form for each person who wishes to be a member of The OAK.  Also, please provide a unique email address for each member.