Name *

First Name

Last Name

Additional Name (if applicable)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone *

(###)

###

####

Is this is a cell phone?

Yes

No

At the moment, my/our plan is to make payments via:

Emmanuel's online giving page (see link below form)

My/Our online bill-paying system

Check or cash

Transfer of stocks or other securities (our Treasurer will contact you to arrange a secure transfer)