If you prefer, you may download and print this form instead of filling it out online: Downloadable PDF Form Step 1 of 3 - Information 33% Personal InformationYour Name* First Last Your Email Address* Your Phone Number*Your Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church InformationChurch NameChurch Pastor NameChurch Email Address Church Phone NumberChurch Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Association InformationAssociation NameModerator NameAssociation Phone NumberAssociation Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you a first-time attendee?* Yes No Church Affiliations The Progressive National Baptist Convention, Inc. National Baptist Convention U.S.A., Inc. Lott Carey Baptist Foreign Mission National Baptist Convention of America National Missionary Baptist American Baptist Full Gospel Baptist Southern Baptist Convention Individual Registrations Quantity Price: $25.00 Quantity Church Registration Quantity Price: $50.00 Quantity Banquet Registration Quantity Price: $40.00 Quantity Voting Delegates Each church is entitled to 10 voting delegates, four of which are included when the full registration fee is paid. For each of the additional six voting delegates, a fee of $25 must be paid. Delegates Included With Registration FeeDelegate 1Delegate 1 Email Delegate 2Delegate 2 Email Delegate 3Delegate 3 Email Delegate 4Delegate 4 Email Additional DelegatesHow many additional voting delegates would you like to register? Quantity Price: Cost per delegate.# of Additional DelegatesPlease enter a number from 0 to 6.Delegate 5Delegate 6Delegate 7Delegate 8Delegate 9Delegate 10 Additional Contributions Please indicate the amount you wish to donate in the spaces provided. Mission ContributionsChildren's Home of VA Baptist Evangelism Board Foreign Mission Home Mission Board Educational ContributionsVUU SDP School of Theology Virginia University of Lynchburg Department ContributionsChristian Education Deacon/Deaconess Young Pastors & Ministers Women in Ministry Ushers Youth & Young Adult CheckoutTotal $0.00 Billing AddressUse My Personal Address (above)Use My Church Address (above)Use a Different AddressBilling Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment MethodCredit/Debit CardCheck/Wire/OtherCredit CardCard Details Cardholder Name Please remit payments to: The Virginia Baptist State Convention, Inc. 22 East Church Street, Suite 208 Martinsville, Virginia 24112CommentsThis field is for validation purposes and should be left unchanged.
