Pastor Smith thanks you for your invitation to share in ministry. Please complete this form to request Pastor Smith for your event. This form is a request for information only and should not be considered a confirmation. Please allow 2 to 3 weeks for a reply. Thank you.

Pastor/Host name:

Church's Name:

Address:

City:

State:

Zip:

Telehone:

Fax:

Office Hours:

Church Website
(if applicable):

Church/Organization
length of existence:

Meeting coordinator:

Telephone number:

Alternate phone number,
(i.e)pager or cell phone:

E-mail address:

Requested day and date
of ministry:

Service time:

Theme:

Special topic requested?

If yes, please list:

Location of meeting:

Physical address:

Telephone number:

Do you allow the sale
of media products?

Other speakers participating
(please list their ministry
dates and times):