Pentecostal Assemblies of the World
Region 3 ICEA
Registration Form
   
  Profile Information
  Name:
  Address:
  City:
  State:
  Zip:
  Telephone:
  Mobile:
  Email Address:
  Emergency Contact Name:
  Telephone:
  Mobile:
  Church/Jurisdiction Information
  Church Name:
  Church Address:
  City:
  State:
  Zip:
  Pastor:
  Jurisdictional Bishop:
  Please check all that apply: Church Registration ($50.00)
Adult Registration ($25.00)
Children Registration(18 & up) $12.00
GTSC
HACC
MDC
MWDDC
  Quantity: Church
Adult
Children
  Security Code