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GENERAL INFORMATION:
Position in Church Ms/Mrs/Rev/Mr
First Name Last Name
Mailing Address
City State Zip Code
E-mail address Re-type e-mail
Telephone: Day Evening |
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CHURCH INFORMATION:
Church/Ministry/Organization
Church Mailing Address
City State Zip Code
Church Phone
Group Registration: Contact Person
Contact Person: Phone Number
Contact Person: E-mail Address |
CREDIT CARD INFORMATION:
Credit Card: Visa M/C Debit Card American Express
Card #
Expiration Date
Name Printed on Card
Card Holder's Telephone Number
Mailing Address if different than above
City State Zip Code |
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Only one registrant per form please. Non-refundable, but transferable,
fee per peson must accompany registration information. |
OFFICE USE ONLY:
File #____________ Received____________ DD______________ Confirmation_____________ |
