Registrant Information

Officiant
Chapel or Organization
Contact Person (If different)
Title 

  Address 

   City
   State or Providence
  Zip/Postal Code 
Country
  Phone
 Phone (Toll Free)
 Fax

    E-mail

Website 
  Services Provided

 (check all that apply)
Weddings
Renewal of Vows
Funerals/Memorial Services
Blessing of Children
Baptisms/Confirmations
Holy Unions
Pre-marital Counseling
Family/Individual Counseling
Public Prayers
Other (Please list)

 State(s) or Province(s) in 
which you are licensed

Denomination/Religious 
Affiliation 

 

Full Listing/Web-Site Linkage   $50 (per year)

                                    Information on services provided (Please limit to 25 words)

Method of Payment

Credit Card
Credit Card Number
Exp. Date

Name on Card

Billing Address (if different) 

Amount





 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Photographs e-mailed should be formatted in .jpg format at 72 dpi. clergy@clergyservices.com 

Photographs may be mailed to:
Clergy Services, Inc.
PO Box 32333
Kansas City, MO 64171.

Photos will be returned upon request.