FAITH-BASED ASSOCIATES FORM Form Church (FBO) Name * Pastor (CEO) Name * First Last Primary Contact * First Last Primary Contact Title * Email Address * Website Address Business Address * City * State * ZIP Code * Phone Number (for Primary Contact) * Fax Number Payment - Please check one: * Now via Check* Invoice me for Full Amount Invoice me for Two Equal Monthly Payments Invoice me for Three Equal Monthly Payments *Please make checks payable to: Crime Stoppers of Michigan—Write ‘Project Good Samaritan’ on the memo line Member Contact Information: Include Name, Title, Mailing Address, and E-Mail I would be interested in serving on a Faith-Based Program Focus Group * Yes No We would be interested in securing volunteers for Crime Stoppers events * Yes No We would be interested in securing volunteers for Community Response Team * Yes No We would be interested in being a host site for a Project Good Samaritan District * Yes No Please list ministries, outreach programs, trainings and/or certifications currently existing/operating in your congregation or FBO that could assist Project Good Samaritan in our work of serving families victimized by crime: Crime Stoppers of Michigan is a 501(c)(3) organization. All contributions are tax deductible to the extent permitted by law. CONTACT Please take a moment to share any feedback, questions or concerns you may have! Bishop James A. Williams, II, Faith-Based Program Manager james@michiganalliance.org 313-922-5000 EXT. 120 313-922-5001