First Name __________________________________ Last Name_______________________

Conference/Association _________________________________________________________

Church Name _________________________________________________________________

Church Address ______________________________________________________________

City ______________________________________________ State ________ Zip ________

Church Phone ______________________________ Church Fax ______________________

Church Email Address _________________________________________________________

Church Web Address __________________________________________________________

Est. Number of Members ______________________ Avg. Attendance _________________

Primary Contact Information for God is Still Speaking at your local congregation

Name __________________________________________________________________

Phone _________________________________________________________________

Email Address___________________________________________________________

Alternate Contact Information for God is Still Speaking at your local congregation

Name __________________________________________________________________

Phone _________________________________________________________________

Email Address __________________________________________________________