BRSG REGISTRATION FORM

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone - ### - ### ####
Office Phone - ### - ### ####
Email *
Affiliation *
Number of Registrants *
Name of Guest/s

Please separate each guest's name with a comma.
Status
Faculty Student Clergy Laity
Check all that apply
Payment *

Payment Check Paypal/Credit Card
Please make checks payable to the Black Religious Scholars Group, 411 21st Ave. S., Nashville, TN 37240. All checks must be received prior to November 16, 2015. *
I have read and agree
Please submit credit card payment through the Paypal link at the bottom of the confirmation page. *
I have read and agree