Ebenezer Baptist Association Church Membership Form 

                                       Ebenezer Baptist Association

                                            1084 Cole Harbor Road

                                         Blackstone, Virginia 23824

                                    ebenezerbaptistassociation.org

Ebenezer Baptist Association Compliance Affidavit/Membership Form

Church Name: _________________________________________________________

Address: ______________________________________________________________

City/State & Zip Code: _________________________________________________ _

Area Code & Phone Number: _____________________________________________

Fax Number: __________________________________________________________

E-Mail Address: _______________________________________________________

By executing this affidavit, the undersigned certifies the above named Church will comply (when accepted) with the Ebenezer Baptist Association Constitution as outlined in Article II membership, Article IV: Mission Statement and Objectives.

Pastor: _________________________________________________________________

Address: ________________________________________________________________

City/State & Zip Code:  ____________________________________________________

Area Code & Phone Number: _______________________________________________

E-Mail Address: __________________________________________________________

Signature: ______________________________________________________________

Chairman of the Diaconate Ministry: _________________________________________

Area Code & Phone Number: _______________________________________________

Signature: ______________________________________________________________

Church Clerk: ___________________________________________________________

Address: _______________________________________________________________

City/State & Zip Code: ____________________________________________________

Area Code & Phone Number: _______________________________________________

E-Mail Address: __________________________________________________________

Annual Dues: $500.00  

Please mail application to:  Ebenezer Baptist Association

Attn: Miss Margaret Pilson

Post Office Box 57

Kenbridge, Va. 23944