Please use this form to request Pastor Jeremy for a speaking engagement.  We are humbled that you have decided to contact us and look forward to working with you and your congregation to further the Kingdom.  God bless you!

First Name: *		Last Name: *
Church/Organization:		Position:	Select OnePastorElderDeaconMemberOther
Date Requested: *		E-Mail: *
Address1:		Address2:
City:		State: *	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI
Zip Code:		Phone: *
Comments:
Verification Code:		Enter Code: *
* Required