Mount Pilgrim Baptist District Association Universal Representation Form
Post Office Box 2245 Birmingham, AL 35201-2245
1 Board Meeting 1 Semi Annual Session 1 Annual Session 1 OTHER ______DATE ______
NOTE: You may write ONE check for Grand Total
Church Name ______Church Address ______City / AL / Zip ______
Church Email ______Church Phone: ______
Pastor ______Pastor Phone: ______
Please Check One: 1 President 1 Supervisor 1 Counselor 1 Laymen 1 Pastor 1 Member
Name ______
Address ______City / AL / Zip ______
Phone ______Email ______
CHURCH Representation: All Pastors and Churches are asked to please consider Church Classification as follows:
1 A: 300 or more Members = $300 1 B: 101 – 299 Members = $200 1 C: Less than 100 Members = $100
Amount $______
PASTOR & Minister: (Amount not included in Church Representation)
Please Check One: 1 Pastor = $25 1 Ordained Minister = $20
1 Licensed Minister = $15 1 Missionary or Ambassador = $25
Amount $______
EXECUTIVE Board Member: $1,000.00 (Annual requirement per the Constitution)
Name ______Amount $ ______
PERSONAL: (List Youth on separate sheet and attach) Adults = $15 Youth Presidents = $5 Other Youth = $1
Name Auxiliary Amount
______
______
______
______
(List additional Adults and/or Youth Presidents on separate sheet and attach) Amount $ ______
______
MISSIONARY Societies: 1 Class A: = $100 1 Class B: = $50 1 Class C: = $30
Please indicate number of Attendees for each category:
1 Matrons = $25 1 Laymen = $15 1 Minister Wives & Widows = $25
1 Nurses = $20 1 Crusaders = $5 1 Deacon & Trustee Wives = $15
1 Sunbeams = $5 1 YWAs = $5 1 Red Circle = $5
______Committee/Other (Please insert name) = $______
Amount $ ______
FOR REGISTRATION USE ONLY: Personal Enrollment (Adult Only): #______$______
Amount Collected: CASH $ ______CHECK $______GRAND TOTAL $ ______
Money Received by: ______Date Received: ______Rev 2/2013