Name (Exactly as it is on Passport): ________________________________
(Note: Passport must be valid for at least 6 months beyond the date(s) of travel to Indonesia)
City: _____________________________ State:_____Zipcode: __________
Telephone: Day: ____________________ Evening: ___________________
e-Mail address: ________________________________________________
Emergency Contact-Name____________________ Phone: _____________
Emergency Contact-Name____________________ Phone: _____________
What are your goals/expectations in participating in this mission trip to Indonesia?

What previous mission experience do you have in other countries? (None required)

List any skills/assets you have that may be particularly useful on this mission:
(eg: teaching, working with children, language skills, artistic, etc.)

Do you have a passport that will not expire prior to December 31, 2014?
YES________ NO ________ (Circle one) Expiration Date: _________

Are there any special accommodations you are aware of that must be met to assure your safety during the trip?

Have you reviewed the U.S. State Department information/warnings on travel to Indonesia? YES_______ NO ________ (Circle one)

____________________________________________ _________________
Signature / Date

$100.00 deposit paid: ___________________ Date: ____________________
Check Number:___________________ Other: ________________________
(The check should be made out to St. Mark Lutheran Church (ELCA), indicating on the comment line that it is for Travel Indonesia Mission 2014).

This form may be mailed with your check to:
Clyde E. Pearce
4610 Campus Circle, Unit 22
Anchorage, AK 99507

Or forward them directly to St. Mark, and send a copy of the application to
Clyde Pearce.

If you have any questions you may call Clyde Pearce at 907-350-8076, or Kristi Johnson at 907-276-9395, or send e-mail to: