* Must have to process order!

Church of Christ Business Owner/Rep's Name: * (ex.: Paul Jones)

Company's Name: * (ex.: ABC, Inc.)

Company's Address:  * (ex.: 111 South Park)

City & State:  * (ex.: Dallas, TX)

Zip:  * (ex.: 75240)

Company's Phone # : * (ex.: 214-333-3333)

Web site Address: (ex.: www.abcinc.com)

Email Address: (ex.: sales@abcinc.com)

City Listing: * (ex.: Dallas, TX)

Category 1:  *(ex.: Marketing)

Category 2:  (ex.: Consulting)

Category 3:  (ex.: Web site Designers)

Nationwide Listing: Yes or No

Category 1:  (ex.: Marketing)

Category 2:  (ex.: Consulting)

Category 3:  (ex.: Web site Designers)

Offering Discount for COC Members: Yes or No

Congregation's Name: *(ex.: Eastside Church of Christ)

Congregation's City & State: *(ex.: Dallas, TX)

Congregation's Phone #: *(ex.: 972-555-5555)

If you have a sales person, please give their name so they will receive their commission for this sale.
Sales Person's Name:

Additional Information: