Full Name:

Guest Name:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Cell Phone:

Email Address:

Since this is a FREE seminar we must know that you are serious about attending, for there will be people who will want to attend, but cannot because seats are filled. We require your credit card information for a $100 fee. This is to ensure your attendance, and will only be processed in the event of your absence. So, if you say you are coming, we want to be sure you will be there for your blessings.

Credit Card Type:
  Select One Visa Mastercard American Express Discover
Credit Card Number :
 
Expiration Date :