Application

FBMI Application

Step 1 of 23

Type of Missionary service for which you are applying*
- Team
- Individual
- Both
Country or Place of Interest*
Date or projected date of Bible College Graduation*
Marital Status*
- Single
- Married
- Engaged

General Information
Name*
Prefix First Middle Last
SSN*
Birthday*
Country of Citizenship*
Spouse's Name
Prefix First Middle Last
SSN
Country of Citizenship
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Names of Children

Name	Birthday

Current Church Membership
Church Name*
Church Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Church Phone*
Pastor's Name*
Prefix First Last Suffix
Have you been ordained:*
- Yes
- No
Please indicate church and date:*
Church Date

Education History
High School*
Graduated?

Colleges and/or other training:

Please indicate all education beyond High School

Institution	Graduated?

Other Special Training

Employment History

List present and previous employers:*

Present or most recent employer first

Name of Employer	Dates Employed	Type of Employment	Supervisor's Full Name	Phone Number

Christian History
Approximate date of your salvation:*
Approximate date of your baptism:*
Relate briefly the testimony of your salvation:*
Describe your daily walk with God*
Include a description of your devotional life
Explain your call to full-time Christian service:*

In what Christian service are you and have you been involved:*

i.e. bus ministry, nursing home ministry, Sunday School classes, etc. Please include length of time involved

Ministry	Length of time

When did you lead your last soul to Christ:*
How many souls have you led to Christ in the last 30 days:*
Briefly give one or two examples of someone that you have led to Christ including their names:*
How many converts have you seen baptized in the last 30 days:*
Briefly give one or two examples of someone that you have helped lead to spiritual maturity:*

Personal Call to Missions
Explain why you sense God's call to missionary service:*
Is there a specific type of ministry you feel called to do?*
What do you believe is the purpose of a missionary?*
What do you believe is the purpose of a church?*
Have you ever applied for or served with another missions agency?*
- Yes
- No
Please give the name of the Agency, and explain why you are no longer affillated with them.*
Does your pastor recognize and support God's call in your life to the mission field:*
Does your church support your applying to FBMI:

Personal Convictions
What does it mean to you to be a Baptist:*
What do you consider to be core doctrines of the Faith:*
What are your convictions regarding the KJV:*
What do you believe are Biblical guidlines for modesty:

Personal References
Please give names and contact information of four references in the following order:
Your sending church Pastor:
Name
First Last
Phone
Email
Another pastor whom you know:
Name*
Prefix First Last
Phone*
Email*
A ministry leader with whom you've served:
Name*
Prefix First Last
Phone*
Email*
A faculty member from Bible College:
Name*
Prefix First Last
Phone*
Email*

Personal Information
Do you currently have a passport:*
- Yes
- No
What is the expiration date:*
Date Format: MM slash DD slash YYYY
Have you ever been denied a passport or visa?*
- Yes
- No
Please give explanation*
Have you ever been divorced, widowed, or had a marriage annulled:*
- Yes
- No
Please give explanation*
Do you currently use tobacco:*
- Yes
- No
Have you ever used tobacco:*
- Yes
- No
When did you last use tobacco:
Do you drink alcoholic beverages:*
- Yes
- No
Have you ever drunk alcoholic beverages:*
- Yes
- No
When did you last drink alcoholic beverages:
Do you attend movies:*
- Yes
- No
Have you ever attended movies:*
- Yes
- No
When did you last attend movies:
Do you attend dances:*
- Yes
- No
Have you ever attended dances:*
- Yes
- No
When did you last attend dances:
Do you use illicit drugs:*
- Yes
- No
Have you ever used illicit drugs:*
- Yes
- No
When did you last use illicit drugs:
Do you have any side effects of drug use:
Have you ever sold illicit drugs:*
- Yes
- No
When did you last sell drugs:
Do you have a court record:*
- Yes
- No
Please upload a statement concerning offenses, dates, and disposition of the case.
Have you ever sought psychiatric counsel:*
- Yes
- No
Please upload a statement concerning circumstances, dates, and medications given.
Is there anything in your past about which we should know:*
- Yes
- No
Please upload a statement directed to Mark Bosje summarizing the information:
What is the general conidition of your health:*
- Excellent
- Good
- Average
- Fair
- Poor
Will you and your family agree to receive the necessary vaccinations for your field of service as recommended by FBMI’s Medical Advisor:*
- Yes
- No

Financial Information
Having an accurate account of your general financial standing is an important step in applying with FBMI. Please answer the following questions as accurately as possible.
Do you currently have any outstanding financial debt:*
- Yes
- No
What is the specific nature of the debt:*
Credit card, mortgage, etc.
What are your current plans to pay off the debt:*

Health Information
This next section is a health history questionnaire which must be completed carefully in detail, answering all questions for both you and your spouse. The questionnaire is reviewed by our Medical Advisor before acceptance by FBMI. Records are kept in the strictest confidence and will not be released to unauthorized persons.

Your Health Section
General Information
Name
Prefix First Last
Age
Type of work you expect to do on the field:
When do you expect to go on the field:
Your birthplace:
Principle nationality of your father:
Principle nationality of your mother:

States or countries where you have resided:

Indicate if urban, rural, farm, etc. as well as dates lived there

Where	Urban, Rural, etc	Dates

Were you ever rejected for military service:
- Yes
- No
Please give explanation
Were you ever in the Armed Forces:
- Yes
- No

List

Unit	Dates	Where

Type of Discharge
Any service injury or disability:
- Yes
- No
Nature of injury or disability
Receiving compensation?
Describe your present health in your own words:

Occupational Information

List jobs of the past five years:

Longest time at any one job:
Any job hazards:
Total time lost from work in past five years due to illness:
Have you ever worked with radioactive materials
- Yes
- No
Explain:
Have you ever been refused employment for health reasons:
- Yes
- No
Explain:
Have you been unable to hold a job because of:
Sensitivity to chemicals, dust, sunlight, etc.
- Yes
- No
Explain:
Inability to perform certain motions
- Yes
- No
Explain:
Inability to assume certain positions
- Yes
- No
Explain:
Other medical reasons
- Yes
- No
Explain:

Insurance and Institutional Information
Have you ever applied for disability or unemplyement compensaion
If so, please indicate which
What physical weak point do you feel might handicap you in missionary work
Have you ever been denied insurance on health basis
What hospitalization insurance do you have?
Any know deformaties or birthmarks?

List the main reasons for hospitalizations, doctor's visits, or serious accidents in the last three years:

Health Information
Physical Characteristics
Height
Weight
Last year weight gain or loss:
Maximum Weight When
Color of hair
Color of eyes
Identifying marks
Right or Left Handed:
Blood Pressure
Habits
How much coffee do you drink daily
How much tea do you drink daily

What medicines are you currently taking on a regular basis

Do you eat breakfast regularly:
Describe an average breakfast:
Describe an average lunch:
Describe an average evening meal:
Have you ever followed any special type of diet
- Yes
- No
Please describe the diet:
How much sleep do you average per night:
What is your usual bedtime:

List any sleep problems

What is your usual hour of arising
Do you fall asleep quickly
- Yes
- No
Do you use any sedatives
- Yes
- No
Specify:
Do you participate in any sports

Family History

Please indicate below with each of your direct family members: Father, mother, and any brothers, sisters, children whether or not they are living, their current age/age at death and any diseases that they did or their cause of death

Relation	Living	Age	Disease/Cause of death

Father
Is he living?
- Yes
- No
Cause of Death
Age
Any diseases?
Mother
Is she living?
- Yes
- No
Cause of Death
Has any blood relation (parent, brother, sister, etc.) or spouse had:
Tuberculosis
- Yes
- No
How related?
Syphillis
- Yes
- No
How related?
Diabetes
- Yes
- No
How related?
Kidney Trouble
- Yes
- No
How related?
Cancer
- Yes
- No
How related?
Heart Trouble
- Yes
- No
How related?
Arteriosclerosis
- Yes
- No
How related?
Disease of nervous system
- Yes
- No
How related?
Rheumatism (arthritis)
- Yes
- No
How related?
Stomach trouble
- Yes
- No
How related?
Asthma
- Yes
- No
How related?
Epilepsy
- Yes
- No
How related?
Mental Problems
- Yes
- No
How related?
Committend Suicide
- Yes
- No
How related?

Past Medical History
Infectious Diseases
Indicate whether you've ever had any of the following
- Measles
- Mumps
- Whooping cough
- Chicken Pox
- Scarlet Fever
- Erysipeias
- Rheumatic Fever
- Swollen/painful joints
- Polio
- Meningitis
- Tonsilitis
- Pneumonia
- Pleurisy
- Diptheria
- Typhus
- Typhoid
- Malaria
- Brucellosis
- Glandular fever
- Parasitic infection
- Tuberculosis
Have you ever lived with anyone who had tuberculosis?
Eyes, Ears, Nose, Throat, Dental
Indicate whether you've had any of the following
- Injury to eye
- Visual Trouble
- Glasses
- Sore eyes (pink eye)
- Aching eyes
- Earaches
- Discharge from the ears
- Ruptured eardrum
- Hearing Difficulty
- A hearing aid
- Bleeding gums
- Severe tooth trouble
- Dentures
- Sinusitis
- Continuous nasal discharge
- Regular nosebleeds
How long have you worn glasses?
Cardio, Respiratory
Indicate whether you've ever had any of the following
- Frequent colds
- Sore throats
- Prolonged cough
- Coughing blood
- Coughing pus
- Night Sweats
- Asthma
- Pain or pressure in chest
- Palpitation or pounding heart
- High blood pressure
- Low blood pressure
- Shortness of breath whith walking
- Shortness of breath lying on your back
- Swelling of legs/ankles
- Known heart trouble
Comments on anything above:
Genital, Urinations
Indicate whether you've ever had any of the following
- Frequent urination
- Painful urination
- Difficulty Urination
- Kidney Stone
- Loss of bladder control
- Blood in urine
- Sugar or albumin in urine
- Disease of genital organs
- Kidney or bladder trouble
- Treatment for venereal disease
Bone, Joint
Indicate whether you've ever had any of the following
- Arthritis or rheumatism
- Painful or swollen joints
- Bone deformity
- Muscle stiffness
- Lameness
- Loss of arm, leg, finger, toe
- Recurring backache
- Painful or trick shoulder or elbow
- Trick or locked knee
- Joint dislocation
- A brace or back support
- Whiplash injury
- Foot problems
Comments on anything above:
Skin
Indicate whether you've ever had any of the following
- Sensitive skin
- Boils
- Severe itching
- Skin rash
- Athlete's foot
- Much sweating
Comments on anything above:
Allergy, Metabolism
Indicate whether you've ever had any of the following
- Hives
- Hay fever
- Asthma
- Allergy of any sort
- Any reaction to serum, drugs, or medicine
- Reaction to penicillin
- Food allergy
- Sensitivity to heat
- Collapse from heat
- Goiter
- Thyroid problems
- High or low blodd sugar
Comments on anything above:
Digestive
Indicate whether you've ever had any of the following
- Difficulty swallowing
- Frequent indigestion
- Heartburn
- Frequent nausea, vomiting
- Piles (hemmorhoids) or rectal trouble
- Black Stools
- Light colored stools
- Frequent constipation
- Episodes of Diarrhea
- Dysentary (blood and mucus)
- Stomach, liver, and intestinal trouble
- Gallbladder trouble or gallstones
Comments on anything above:

What foods disagree with you:

What medicine have you taken for stomach trouble:
Frequency of laxatives and what kind:
Nervous
Indicate whether you've ever had any of the following
- Neuritis
- Injury causing unconsciousness
- Paralysis of any part of the body
- Difficulty in coordination
- Epilepsy, fits, or blank spells
- Frequent or severe headaches
- Pressure in the head
- Dizziness or fainting
- Double vision or spotty vision
- Car, train, sea, or air sickness
- Stuttering or stammering
- Numbness or tingling of any part of the body
- Twitching of face, head, shoulders
- Morning fatigue
- Easy fatigue with working
- Frequent trouble sleeping
- Frequent or terrifying nightmares
- Sleep walking
- Depression or excessive worry
- Loss of memory or amnesia
- Bed wetting
- Nervous exhaustion
- Nervous breakdown
- Homosexual tendencies
- Any sex problem
- Drug or narcotic habit
- Desire to commit suicide
Comments on anything above:
Any written explanation of these problems can be uploaded here to be handled confidentially by our Medical Advisor or Missions Director. Please contact the Missions Director for clarification on enclosed files.
Have you ever consulted a neurologist, psychologist, psychiatrist, or counselor for any matter?

Rate yourself on a scale of 1-5 in regard to the following characteristics, 5 being the highest
Nervous - Tense, high-strung, apprehensive
Composed - Calm, relaxed, tranquil
Depressive - Pessimistic, discouraged, dejected
Light-hearted - Happy, cheerful, optimistic
Active/Social - Energetic, enthusiastic, socially involved
Quiet - Socially inactive, lethargic, withdrawn
Expressive/Responsive - Spontaneous, affectionate, demonstrative
Inhibited - Restrained, unresponsive, repressed
Sympathetic - Kind, understanding, compassionate
Indifferent - Unsympathetic, insensitive, unfeeling
Subjective - Emotional, illogical, selfabsorbed
Objective – fair-minded, reasonable, logical
Dominant – Confident, assertive, competitive
Submissive – Passive, compliant, dependent
Hostile – Critical, argumentative, punitive
Tolerant – Accepting, patient, humane
Self-disciplined – Controlled, methodical, persevering
Impulsive – Uncontrolled, disorganized, changeable
If married, how do you rate your relationship to your spouse?
If you have children, how do you rate your relationship with your children?
How do you rate your relationship to your parents?
If unmarried, how do you rate your relationship to your family?
How would your rate your relationship with other close associates?

Surgery
Please indicate if you currently or have ever had:
- Tumor, growth, cyst
- Cancer
- Rupture
- Appendicitis
- Skin mole removed
- Goiter
Comments on anything above:

Please list any operations you have had or have been advised to have:

Operation	Doctor and address	Why advised	Date

Please list any hospitalizations you have had or have been advised to have:

Hospital	Doctor and address	Why advised	Date

Please list any accidents or serious injuries you have had:

Accident/injury	Date

Miscellaneous
Have you ever had:
Physiotheraphy or heat treatments
- Yes
- No

Reason	Practitioner	Date

Chiropractic adjustments
- Yes
- No

Reason	Practitioner	Date

Colonic irrigations
- Yes
- No

Reason	Practitioner	Date

Naturopathic treatments
- Yes
- No

Reason	Practitioner	Date

Foot treatments
- Yes
- No

Reason	Practitioner	Date

Other Special treatments
- Yes
- No

Reason	Practitioner	Date

Have you ever had any illness or injury other than those already noted?
- Yes
- No
Explain:
Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the last five years?
- Yes
- No
Explain:
Have you ever had an undiagnosed weakness, chills, and/or fever?
- Yes
- No
Explain:
Have you ever had rapid weight gain or loss?
- Yes
- No
Explain:

Spouse's Health Information
General Information

Autobiographical Sketch
Stressful situations are met on any mission field with respect to coworkers and the indigenous peoples. Emotional maturity and social compatibility are required. For this reason, a resume of your background and relationship to family and friends is requested in this evaluation. Please write an autobiography in essay style, using appropriate paragraphs, treating in detail the subjects indicated. The outline which follows is only a guide and is not to be copied or answered in question and answer fashion. Use as many sheets as required, with your name and page number on each. A. FAMILY BACKGROUND 1. Your birthplace, home, and parents: Were your parents compatible, happy, or the converse? List the children born to your parents in order of birth. Were you raised in a Christian home? 2. Mention others who lived in the same household for any time during your growing-up period, i.e. relatives, boarders, hired hand, housekeeper, servants, etc. Mention, if appropriate, foster parent, step-parent, divorce, etc. FATHER 1. His occupation and work habits during your childhood 2. His personality and habits in relationships with people 3. Your personal relationship with him and any significant changes in it as you matured MOTHER 1. Her occupation, if she worked for long periods during your childhood 2. Her work at home, amounts of responsibility she took for the work and management of the household 3. Her personality and habits in relationships with people 4. Your personal relationship with her and any significant changes in it as you matured BROTHERS AND SISTERS 1. Describe your relation with each. Indicate if you were an “auxiliary parent” to a younger child or, conversely, if you were in the place of a younger child supervised by an older one. 2. Were there feelings of unusual intensity, positive or negative, with any brother or sister? 3. What was the general atmosphere? Were there jealousies,tensions? Was it a close-knit family or rather on the remote,self-sufficient side? What did you do together (church, games, sports, travel)? 4. Describe present occupation and current age of each brother or sister, marital status, religious affiliation, and present family group. B. SCHOOL 1. Where did you attend grade school, high school? describe briefly two or three events from elementary school. 2. Did you have trouble with teachers? Why? or Why not? 3. High school: favorite subjects; extracurricular activities: school paper, clubs, sports, etc. Did you ever quit school? If so, why? 4. College: relationships with roommates, if any. Did you change majors? Why? In what ways did you mature? C. SOCIAL 1. Clubs, Scouts, 4-H (outside of school), hobbies, church 2. Dating: Review briefly. Attitude toward marriage, children. (See also on E.) D. PERSONAL 1. Are you aware of any extreme likes or dislikes or special fears which have disturbed you in the past? 2. What do you consider your strong points? Weak points? 3. Any lack of emotional control? How do you explain it? 4. Are you unusually sensitive? Have you lost your temper at someone in the last few months? 5. Is sustained concentration difficult? List the books that you have read in their entirety in the last six months. 6. Was there a time of rebellion in your teen or later years? 7. Are you subject to faintness or dizziness? Great fatigue? Prolonged depression? 8. Have you ever had a “nervous breakdown”? Describe. 9. Have you ever sought consultation with a neurologist, psychiatrist, or a psychologist? 10. Describe an instance of relying on spiritual help in time of discouragement. 11. Have you ever tried to offer counsel to someone else in trouble?Describe a case. 12. How often do you have personal, private devotions (time spent, materials used)? Family prayers? 13. Is your spiritual, social, intellectual, and emotional growth basically satisfactory to you? Why or why not? E. MARRIAGE Date of marriage, courtship. Were both Christians at time of marriage? Additional remarks. F. GROUP RELATIONSHIPS 1. Give the name and address of one employer for whom you worked for at least six months who has a personal acquaintance with you and has observed your relationships with your co-workers. 2. Give name and address of one group leader who has observed you for a period of six months in your relationship with the group (Explorers, AWANA, scouts, etc.) working on definite projects together, preferably a group in which you were active beyond the age of sixteen.

FBMI Application

Step 1 of 23

General Information

Current Church Membership

Education History

Employment History

Christian History

Personal Call to Missions

Personal Convictions

Personal References

Your sending church Pastor:

Another pastor whom you know:

A ministry leader with whom you've served:

A faculty member from Bible College:

Personal Information

Financial Information

Health Information

Your Health Section

General Information

Occupational Information

Have you been unable to hold a job because of:

Insurance and Institutional Information

Health Information

Physical Characteristics

Habits

Family History

Has any blood relation (parent, brother, sister, etc.) or spouse had:

Past Medical History

Rate yourself on a scale of 1-5 in regard to the following characteristics, 5 being the highest

Surgery

Miscellaneous

Have you ever had:

Spouse's Health Information

General Information

Autobiographical Sketch

MISSIONARIES