National Baptist Convention Event Registration

Mid Winter Board Meeting Registration - MODERATORS

Dr. Kenneth O. Lyons, President
We accept MasterCard, Visa and Discover Cards

Instructions

This form is for registering Districts & Moderators (District Presidents) , Staff and Individuals for the Mid Winter Board Meeting of the National Baptist Convention, USA, Inc. On this form, you will have the opportunity to register and make donations. If you want to register for the Parent Body or a different auxiliary, please go back to the website and choose the correct form. Each form must be submitted separately.

Please review the printed forms and have all your information handy. Changes cannot be made online after you submit your form. You will need to make changes at the Registration Desk.

For technical issues with the online registration system, contact Dr. Denise Mayhan at webmanager@nationalbaptist.com.

* Means required field
What is your State Convention's name? (select)*
Enter State Convention name if not listed:
State Convention President's Name
Prefix First Name Last Name
Enter email address to receive our newsletter (about 6x/yr.)
SECTION A: STAFF REPRESENTATION
Full Name
Prefix First Name Middle Name Last Name Suffix
Personal ID #
Position:

Address

Moderator's Address

District Association Address (if different)

Address

Office Phone Number
- Area Code Phone Number
Fax Number
- Area Code Phone Number
Home Phone Number
- Area Code Phone Number
Email
Please enter any additional comments needed here:
________________________________
Representation Fees and Special Contributions

Select the registration/representation category desired. To make a Special Contribution, select the level of giving ($ increment) the quantity and the category (where you want your gift to be directed). You may enter comments about your donations in the comment box above, if needed.
Registration and Contribution Selections
District Association (4001) $300.00 USD
Personal Representation (4002) $100.00 USD
Special Contributions - $10 increments $10.00 USD

$10 X Category
Special Contributions - $25 increments $25.00 USD

$25 X Category
Special Contributions - $100 increments $100.00 USD

$100 X Category

Total: $0.00 USD
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BEFORE YOU CLICK: Check to be sure that all of your information is correct. When you click the "Submit Form" button you will be redirected to a secure site to enter your credit card payment information.

Your credit card transaction receipt and detailed registration information will be emailed to you in two separate emails.
Should be Empty:

Mid Winter Board Meeting Registration - MODERATORS