State Registration Form

May 22-23, 2008

Name:

Address:

City, State, & Zip Code:

E-Mail Address..............

Phone Number: Area Code: Number:

Registered as: Standing Delegate: Association Delegate: Visitor:
State Officer, State Board Members, Ordained & Wives
Unmarried Widow of Ordained

If Standing Delegate:
State Officer: / Ordained Minister: / Ordained Deacon: / Wife of Ordained:/
Unmarried Widow of Ordained:

Member of Board:

Church:

Association:

If Visitor/ Visiting from Where?