GREATER HARVEST CHURCH

2012 CONVENTION REGISTRATION

Please complete the information below so we may register you for the conference.  Enter your Name as you wish it to appear on your convention Name Badge.

First Name               Last Name          

Title:                       Organization         

Street Address 1 Street Address 2    

City                              State             

Zip Code            

Home/Cell Phone #              Fax #           

Email Address       

Arrival Date             Departure Date  

Method of Payment for the $20.00 Registration Fee   (Children under age 12 register for Free)

Mail In Payment            Pay at Convention Check In Desk              Under age 12 (Free Registration)    

Comments,  Special Needs or Instructions