CONTACT - Insert

This is the congregations contact page used for the local phone directory for local members. Information entered is stored in a database and not made public. The purpose is to create a local and updated phone directory of members of which Mr. Joe Jacoby is collecting for Mr. Sexton. If you do not wish to use this online form, you may print out this page then fill it in and return to Mr. Jacoby. Use extra sheets of paper if necessary. Thank you for your help and support.

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First Name:
Last Name:
Address:
City:
Zip:
Home #:
Cell # 1:	( xxx-xxx-xxxx )
Cell # 2:	( xxx-xxx-xxxx )
Email: ( ie; name@domain.com OR; N/A )
Email 2:
Your Baptism Date:	( mm/dd/yyyy )
Your Spouse's Baptism Date:	( mm/dd/yyyy )
List Your Interests (up to 250 characters):
Your Spouse's Interests (up to 250 characters):
Wedding/Anniversary Date:	( mm/dd/yyyy or; N/A )
Children Names?:
Any Comments? (up to 250 characters):
Are you sure you want to enter this information?:	YES