BENEVOLENCE FUND REGISTRATION

BENEVOLENCE FUND

By completing this form, I am paying $10 to participate in the Benevolence Fund with Virginia Church of God. EACH INDIVIDUAL MUST COMPLETE THIS FORM TO BE A PARTICIPANT. Your spouse is NOT automatically a participant, but must complete this form separately in its entirety.
Participant's Name*

First NameLast Name
Check One*
Participant's Address*

Mailing Address

Street Address Line 2

CityState

Postal / Zip Code
Church of God You Attend*
Type the name of the church above.
Participant's E-mail*

Confirmation Email
Beneficiary Information

Please name a Beneficiary #1 (required). A second Beneficiary (#2) is optional. The details for any beneficiary you designate are required in full.
#1 BENEFICIARY'S Name*

First NameLast Name
#1 BENEFICIARY Address*

Mailing Address

Street Address Line 2

CityState

Postal / Zip Code
#1 BENEFICIARY Main Phone Number*
#1 Beneficiary's Relationship to Participant*
Choose Relationship from DROPDOWN FIELD above.
BENEFICIARY #2 INFORMATION
#2 BENEFICIARY'S Name

First NameLast Name
#2 BENEFICIARY Address

Mailing Address

Street Address Line 2

CityState

Postal / Zip Code
#2 BENEFICIARY Main Phone Number
#2 Beneficiary's Relationship to Participant
Choose Relationship from DROPDOWN FIELD above.
PAYMENT INFORMATION
*We accept VISA/MasterCard/American Express only.

Benevolence Fund for Participant*

ONLY 1 Benevolence Participant$10.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

BENEVOLENCE FUND