Application

fill form below, click submit, someone will respond to you soon!

Just a little information please!

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Year of Birth *

Name of Company You Work For (if retired type retired) *

Years at Current Job? *

If not in trucking please let us know your work industry! *

We would like to know a little about your church you attend!

Name of Church You Attend? *

Church Address *

Line 1

Line 2

City

State

Zip Code

Country

Years Attended *

Pastors Name *

First

Last

Pastors Phone Number *

Pastors Email *

Personal References

Reference #1 Name *

First

Last

Reference #1 Email *

Reference #1 Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference #1 Phone Number *

Reference # 2 Name *

First

Last

Reference # 2 Email *

Reference # 2 Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference # 2 Phone Number *

Reference # 3 Name *

First

Last

Reference # 3 Email *

Reference # 3 Address *

Line 1

Line 2

City

State

Zip Code

Country

Reference # 3 Phone Number *

Once you click submit, we will verify and either approve or deny your application as soon as we possibly can. To expedite things, feel free to text the words (I submitted) to 316-530-1717. Although not a requirement. You will receive an email on the progress of your application. Once approved you will receive a welcome email as well as access to the Chaplains area of our website. Where you will have access to Channel 21 Ministries training center. Feel free to add any comments below, if you like.

Comment *

Submit

fill form below, click submit, someone will respond to you soon!

Just a little information please!

We would like to know a little about your church you attend!

Personal References

Take Me Back
to Lonesome Road Ministries Home

Take Me Back
to Channel 21 Ministries
Home

Lonesome Road
Ways to Listen
Click Here

Tax Deductible
Donations Thankfully
Accepted Here!

fill form below, click submit, someone will respond to you soon! ​

Just a little information please!

We would like to know a little about your church you attend!

Personal References

Take Me Backto Lonesome Road Ministries Home

Take Me Backto Channel 21 Ministries​Home

Lonesome RoadWays to ListenClick Here

Tax Deductible​Donations ThankfullyAccepted Here!

fill form below, click submit, someone will respond to you soon!

Take Me Back
to Lonesome Road Ministries Home

Take Me Back
to Channel 21 Ministries
Home

Lonesome Road
Ways to Listen
Click Here

Tax Deductible
Donations Thankfully
Accepted Here!