District Congress Registration
STOP! MAKE SURE YOU HAVE DOWNLOADED AND READ THE ENTIRE CHURCH PACKAGE BEFORE COMPLETING THIS REGISTRATION FORM.
CHURCH NAME
*
CHURCH ADDRESS
*
CITY
*
STATE
*
ZIP
*
CHURCH PHONE
*
PASTOR'S NAME
*
CHURCH OR PASTOR'S EMAIL
*
CHURCH REGISTRATION
*
$400.00 (OVER 300 CHURCH MEMBERS)
$320.00 (150 - 299 CHURCH MEMBERS)
$240.00 (3 - 149 CHURCH MEMBERS)
PASTOR REGISTRATION
*
$25.00
CURTIS L. WIGGINS SCHOLARSHIP
$100.00
$75.00
$50.00
DISTRICT OFFICER REGISTRATION
$25.00
LIST OFFICER NAME
DISTRICT OFFICER REGISTRATION
$25.00
LIST OFFICER NAME
DISTRICT OFFICER REGISTRATION
$25.00
LIST OFFICER NAME
DISTRICT OFFICER REGISTRATION
$25.00
LIST OFFICER NAME
NOTE: IF YOU HAVE MORE THAN 4 DISTRICT OFFICERS PLEASE CONTACT DEAN CHERYL BROOKS AT 321-725-1791
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
DELEGATE NAME
DELEGATE'S EMAIL
DELEGATE'S PHONE #
COURSE #
NOTE: IF YOU HAVE MORE THAN 10 DELEGATES CONTACT DEAN CHERYL BOOKS AT 321-725-1791
TOTAL AMOUNT FOR ALL REGISTRATIONS
*
Email OF PERSON COMPLETING THIS REGISTRATION
*
Website/URL
PAYMENT INSTRUCTIONS
ONCE YOU HIT SUBMIT YOU WILL RECEIVE A CONFIRMATION EMAIL. CLICK ON THE WEBSITE URL AT THE BOTTOM AND YOU CAN MAKE ELECTRONIC PAYMENT THRU THE DONATE BUTTON
If you are human, leave this field blank.
Submit
Δ