Name *

First Name

Last Name

Spouse's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Spouse's Phone

(###)

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Please check all that apply

This is my first visit

I would like a call from a minister

I am interested in becoming a member of Jefferson

I would like for someone to contact me about baptism