Enrollee Type
*
Please Select
Church
Individual
Enrollee Name
*
Mailing Address
*
City
*
State/Province
*
Please Select
--- USA --
AL
AK
AZ
AR
CA
CO
CT
DE
DC
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
--- Canada ---
AB
BC
MB
NB
NF
NS
NT
ON
PE
QU
SK
YT
Postal Code
*
Phone
*
Email
*
example@example.com
Type of Pledge (Choose One)
*
Pledge Increase
New Pledge
Increase amount from:
*
Increase amount to:
*
Effective (Month)
*
Please Select
01
02
03
04
05
06
07
08
09
10
11
12
Effective (Year)
*
Please Select
2024
2025
2026
New Pledge Amount:
*
$50
$75
$100
$200
Other
Effective (Month)
*
Please Select
01
02
03
04
05
06
07
08
09
10
11
12
Effective (Year)
*
Please Select
2024
2025
2026
Signature
*
Signature of Individual
*
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