PROGRESSIVE NATIONAL BAPTIST CONVENTION, INC.
601 – 50th Street, NE Washington, DC 20019 www.pnbc.org
STATE CONVENTION, STATE FELLOWSHIP,
ASSOCIATION & LIFE MEMBER REGISTRATION FORM
Section 1: Completed by State Convention, State Fellowship or Association only
Check One: ¨ State Convention ¨ State Fellowship ¨ Association
Type of Membership: New ¨ Renewal ¨
Name:
Address
City State Zip
Email______Cell Phone (______)______-______
PHONE ( ) FAX (______)______- ______
LEADER’S NAME ______PHONE ( ) -
______
Section 2: Completed by Individual Life Member only
Type of Membership: New ¨ Yes ¨ No ¨
Name:
Address
City State Zip
Email______Cell Phone (______)______-______
Church Name ______
Church Address ______City ______State ______Zip______
______
Section 3: Completed by all
ANNUAL MEMBERSHIP FEES (Check One)
¨ State Convention: $1,000.00 [2 delegates] ¨ State Fellowship: $ 500.00 [2 delegates]
¨ Association: $ 300.00 [1 delegate] ¨ Individual Life Member: $1,000.00 [1 DELEGATE]
Church Name (Individual Life Member Only)
Remittance Schedule: Annual Semi-Annual Quarterly Monthly Weekly
Prepared By Date
Signed By Date
Please list delegate info on other side of form!
Payment Details
Method of Payment: [ ] Check [ ] Money Order Credit Card [ ] AE [ ] VISA [ ] Mastercard [ ] Discover
Credit Card # ______Signature ______
Please Print Name as it Appears on Card: ______Expiration Date: ______
TOTAL AMOUNT REMITTED: $ ______
STATE CONVENTION, STATE FELLOWSHIP
ASSOCIATION & LIFE MEMBER REGISTRATION FORM
All individuals age 21 and older registering for the PNBC Annual Session
must pay the $75 [pre-registration] or $100 [on-site] general registration fee.
Departmental fees and congress class fees are paid in addition to the general registration fee.
Delegate Fees: $75.00 Pre-registration $100.00 On-site
Messenger Fees: $75.00 Pre-registration $100.00 On-site
DELEGATES
NAME EMAIL
1. ______
2. ______
3. ______
MESSENGERS
NAME EMAIL
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______
8. ______
9. ______
10. ______
RETURN COMPLETED FORMS TO: PNBC 601 50TH STREET, NE WASHINGTON, DC 20019
CREDIT CARD PAYMENTS MAY BE FAXED TO 202-398-4998 OR EMAILED TO