Registration

Please use this form to register with Center for Prayer Mobilization.
Please make sure that all of fields are completed properly so we can process your
application in a timely manner. Thank you. (* = required fields).

*Name:
*Email Address:
*Street Address:
*City:
*State:	Select State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnectDist of ColDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolNorth DakNebraskaNew HampNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennRhode IsSouth CarolSouth DakTenesseeTexasUtahVirginiaVermontWashingtonWisconsinWest Vir.Wyoming
*Zip:
*Day Phone:
Evening Phone:
Fax:
Mobile/Cell:
Referred By:
Currently Attending Church?:	Yes No
If Yes, Name Of Church:
Number of People:
Important Note:	A $100 deposit required at time of registration. Deposit refundable if cancellation is a minimum of 30 days prior to Ministry date. Registration confirmation subject to date availability.
Deposit Payment by:	Credit Card / Paypal Mailing a Check