Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Are you a church planter or contacting us from the mother church? *

Church Planter

Mother Church

If church planter, are you currently ordained in the CREC? *

Yes

No

Who is your Pastor? *

First Name

Last Name

Pastor's Phone *

(###)

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