| First Name* |
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| Last Name* |
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| Address* |
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| City* |
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| State* |
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| ZIP* |
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| Birth Date* |
(MM/DD/YYYY) |
| Home Phone |
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| Cell Phone |
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| Email* |
* We will be corresponding with you about your meeting and baptism through email. |
| Please state briefly how and when you accepted Christ as your Savior: * |
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| Why do you want to get baptized? Have you been baptized before (since becoming a Christian)?* |
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| Please Select One:* |
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