Single Delegate Registration

How Do You want to attend?  *

I will be attending in-person - $35

I will be attending virtually - $20

Title  *

--Select-- Dr. Rev. Min. Bro. Sis.

First Name  *

Last Name  *

Address  *

City  *

State  *

Zip

Phone  *

Email  *

Church  *

Church Mailing Address  *

Mailing Address Street,City,State

Pastor's Name

Payment Information

Amount

$

Payment Method *

Pay Now with Credit/Debit Card using Paypal, no account required Mail-In Payment

Billing Zipcode*

Credit Card Number*

Expiration Date*

01 02 03 04 05 06 07 08 09 10 11 12 / 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032

Card (CVV) Code*

Card Type*

Visa MasterCard Discover American Express

Card Holder Name*

Verification code*