For clarification or questions, contact: "Jackie" Dupont-Walker, Consultant Social Action Commission, jdupontw@aol.com p: (323) 734-7856 / f: (323) 734-5003 1621 Wellington Road, Los Angeles, CA 90019Title:Name:*Address:City:*State:*Postal Code:Country:PHONE INFORMATIONDaytime Phone:*Evening Phone:Mobile Phone:EMAIL/WEBSITE INFORMATIONEmail* Website:CHURCH INFORMATIONChurch Name:Church City:Church State:Church Country:Position of Influence:Please describe the resource and/or decision making role of the person listed above.OTHER INFORMATIONIf you are not the person listed above, please provide your contact information below (optional): Name:Daytime Phone:Fax:Mobile Phone:Email Website:What is your connection to the person listed above?May we use your name in confirming this information?YESNOUnsure (explain below)I am unsure because:NameThis field is for validation purposes and should be left unchanged.
