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***Women’s Conference 2012 Group Registration

All Fields Are Required

Group Name:

Church or Group Affiliation:

Number of Attendees:

Group Leader Name:

Group Leader Phone Number:

Group Leader E-Mail Address:

First & Last Names of Attendees - Including Leader (please separate with commas):

Address of Church or Group:

City:

State: (i.e. CT)

Zip:

Church or Group E-Mail Address:

Church or Group Phone Number: