128th Annual Session Voter Registration Form

Name of Person Completing This Form

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Phone:

Church Information

• Church Name
• Name of Pastor
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:

Delegate Information

You may add a maximum of 12