National Baptist Convention Event Registration

Mid-Winter Board Meeting - PARENT BODY

Dr. Julius R. Scruggs, President
CONTACT PERSON INFORMATION

This is the person who will receive receipts and respond to questions we have, if any. If you don't complete this section you will NOT get your email confirmation receipts.
Contact Name*
First Name Last Name
Phone Number*
- Area Code 4444444
E-mail - DO NOT SKIP THIS!!!*
your receipt will be emailed to this address
Enter your email address to receive the Convention's Email Newsletter
Our email newsletter (about 6 times per year)
CHURCHES & INDIVIDUALS: Complete this section to register a Church or Individual. (Skip to the next section for State Conventions.)

Complete for church and individual registrations. If you are registering a State Convention, skip to the next section "State Convention Registration." You will be able to enter individual delegate information in a later section.
Church ID #
Church Name
Our church participates in monthly giving

Yes No
Pastor Name
Prefix First Name Last Name

Church Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Church Phone
- Area Code Phone Number
Pastor's Phone (mobile or office)
- Area Code Phone Number
Church Fax
- Area Code Phone Number
Church Email
Church Website
STATE CONVENTION REGISTRATION: Complete this section to register a State Convention.

If you are not registering a State Convention, skip to the next section - "Delegate Names"
State Convention ID #
What is your State Convention's name?
Enter State Convention name if not listed:
State Convention President's Name
Prefix First Name Last Name
State Convention President's Office Phone
- Area Code Phone Number
State Convention President's Mobile Phone
- Area Code Phone Number

State Convention Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

State Convention Phone
- Area Code Phone Number
State Convention Fax
- Area Code Phone Number
State Convention Email
State Convention Website
Annual Session Date (or Month if not known)
________________________________
DELEGATE NAMES

Enter the names and addresses of all of your delegates below.
1. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
2. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
3. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
4. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
5. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
6. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
7. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
8. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
9. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
10. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
11. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
12. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
13. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
14. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
15. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
16. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
17. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
18. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
19. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
20. Delegate Name
Prefix First Name Middle Name Last Name
Delegate Address
Enter the Delegate's mailing address in the text box above.
________________________________
Representation Fees and Special Contributions

Check the checkbox next to the appropriate registration categories. If needed, select "Additional Delegates" and indicate the number of additional delegates desired. Select the checkbox of the Special Contributions you want to make using the dollar increments as a guide. Enter the quantity and then select where you want your contribution to go.
Registration and Contribution Selections
I am a REGULAR GIVER - no payment included at this time. Note: You may make regular giving and other donations below under the "Special Contributions" category. Free
Church - Minimum Representation (Code #1000) $400.00 USD
Additional Giving (above $400 minimum) - $10.00 Increments $10.00 USD

Quantity
Additional Giving (above $400 minimum) - $100.00 Increments $100.00 USD

Quantity
Additional Giving (above $400 minimum) - $25.00 Increments $25.00 USD

Quantity
Additional Delegates $25.00 USD

# of Additional Delegates
Pastor/Preacher (code #1001) $100.00 USD

# of Pastors/Preachers
Officer (Code #1002) $300.00 USD
Board Member (code #1003) $200.00 USD
State Convention (code #1004) $2,000.00 USD
Personal /Individual (code #1005) $100.00 USD

# People
Special Contributions /Monthly Giving- $10 increments $10.00 USD

$10 X Category
Special Contributions /Monthly Giving- $25 increments $25.00 USD

$25 X Category
Special Contributions /Monthly Giving- $100 increments $100.00 USD

$100 X Category

Total: $0.00 USD
________________________________________________

BEFORE YOU CLICK: Check to be sure that all of your information is correct. When you click the button "Submit Form and Proceed to Payment" 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 - PARENT BODY

CONTACT PERSON INFORMATION

Enter your email address to receive the Convention's Email Newsletter

CHURCHES & INDIVIDUALS: Complete this section to register a Church or Individual. (Skip to the next section for State Conventions.)

STATE CONVENTION REGISTRATION: Complete this section to register a State Convention.

DELEGATE NAMES

Representation Fees and Special Contributions