Wish Me A Merry Christmas - Community Impact Church Application

Please fill out the form below to apply to become a Community Impact Church.

*Pastor's Name *Church Name *Denomination *Street Address *City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming *Zip Code *Pastor's Email Address *Church Phone Number *How did you hear about us? Select Agape - JP Agape-LB Agape - LNQ Blog CBN Daily Press Article Drudgereport Banner Ad Focus on the Family Friend JJM07 K-LOVE MM07 Search Engine Other *How many buttons are you considering ordering? (200 Minimum for the Community Impact Church designation) Please enter a 1-2 sentence statement about why you feel the Wish Me A Merry Christmas Campaign is important. (This statement will be posted to our website and used in press releases to your local media.) Please list any local media (newspaper(s), radio station(s), television station(s)) you would like us to contact with a press release about your involvement in the Campaign

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