Power For Success In Life

If you are interested in having Gerald & Diana present Life-Shaping to your organization, church, ministry or convention, please fill in this form.

Name:  
Title:  
Authorization:

Are you authorized (or working under the direction of a supervisor ) to register speakers for this organization?.

Yes, I am authorized to request this information on behalf of the ministry and or organization listed below.

  
Company, Assoc. Ministry etc:

 
Address:  
City:  
State:  
Zip Code:  
Country:  
Telephone:  
FAX:  
E-mail::  
Other:  
About: Use this space to tell us about the event or ministry you are requesting Gerald & Diana to speak at: (please include proposed dates).