Name  ___________________________________________________________________

Address ________________________________________________

City __________________ State__________ Postal Code ____________ Country________

Phone ________________________________________ 

Email Address  _________________________________

List any certifications and licenses currently held:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

I, (name to be used on certificate)______________________________hereby warrant and affirm that I have completed all of the requirements to become a Licensed Spiritual Healer.

I am a member of the_______________________________________Church.

Signature  ________________________ Date____________

Alliance of Christian HealersLicense Board
8417 Oswego Road #131
Baldwinsville, NY 13027
info.healers @ gmail.com (no spaces)

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