Talent Survey - AME Church

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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 90019
Title:
Name:*
Address:
City:*
State:*
Postal Code:
Country:
PHONE INFORMATION
Daytime Phone:*
Evening Phone:
Mobile Phone:
EMAIL/WEBSITE INFORMATION
Email*
Website:
CHURCH INFORMATION
Church 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 INFORMATION
If 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?
- YES
- NO
- Unsure (explain below)
I am unsure because:
Phone
This field is for validation purposes and should be left unchanged.