Contact 1 — M+D

Your Name*

First NameLast Name

E-mail*

example@example.com

Phone*

Area CodePhone Number

Church/Organization Name*

Pastor's Name (if different from person completing the form)

First NameLast Name

Please enter the website of your church or organization.*

Requested Speaker*

Pastor Myles RutherfordPastor DeLana Rutherford

Name/Type of Service/Event*

Service/Event Date & Time*

MonthDayYear

Hour MinutesAM/PM Option

Allotted Time for Ministry*

Please include the total amount of time allotted including message, altar call, etc.

Please list any additional flexible dates for consideration.

Venue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Expected Attendance

Event Attire

Will there be any additional special guests in attendance?*

YesNo

If yes, please list any special guests that will be in attendance.

Honorarium*

Please indicate the amount of honorarium planned.

Travel Reimbursement*

Travel reimbursement is in addition to honorarium and includes mileage over 50 miles from home church or flights for 2 people, and hotel accommodations. Check the box to acknowledge this agreement.

Hotel Information*

Please provide the name and address of your host hotel.

Is the sale of the speaker's products or merchandise permitted?*

YesNo

How did you hear about our ministry?*

Is there any additional information you would like us to know about your service/event?

BOOK MYLES + DELANA

Rutherford Ministry Request

Event Information

M + D