Name *

First Name

Last Name

Arrival Date - (Check-in: 3:00 PM)

MM

DD

YYYY

Departure Date - (Check-out: 11:00 AM)

MM

DD

YYYY

Your Permanent Address

To include Street Name/City/State/Zip Code

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Cell Number

(###)

###

####

I understand upon submission of this form, if I cannot fulfill this commitment, it is my responsibility to notify First Baptist Church of Lexington AS SOON AS POSSIBLE, so house can become available to other potential missionaries. $100 deposit will be REQUIRED TO HOLD your reservation once confirmed. Cost of stay MUST BE PAID IN FULL prior to arrival. Residents will be responsible to pay usage and upkeep fee of $20/day to help cover the cost of utilities.**Non-FBLex supported missionaries may have to provide additional information prior to confirmation of reservations.

Yes

No