Breakthrough Leadership Conference Information Request

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(* = required field)

Please mail me (check all that apply): *

a free DVD about the Breakthrough Leadership Conference (BLC)
a free DVD and BLC booklet
multiple copies of the BLC booklet to share with other leaders
  How many copies of the booklet: 

Title *

First Name *

Last Name *

I am requesting information about the BLC as: *

An individual
A representative of my church
A representative of my company or organization

Name of the congregation, company, or organization I represent (leave blank if requesting information as an individual)

Street Address *


This is my: *

Home address
Congregation, company, or organization address (as listed above)

City *

State/Province *

ZIP/Postal Code *

Country *

Daytime Phone *

( )    - 

I am a:

Pastor
Other church staff member
Lay leader (volunteer) in a congregation
Leader in a company or organization

I am also a (check all that apply):

Stephen Leader
Stephen Minister
ChristCare Equipper
ChristCare Group Leader

E-Mail *

Password *

Must be 5 to 10 characters long.

Re-type Password *

Why a password?

Your e-mail and password set up an account on our Web site. Creating this account will save you from retyping your address information if you return to our Web site to request additional BLC materials or to order from our Web store.

In the future, to log in, use your e-mail address as your log-in name and the password you entered above.

What prompted you to request information about the BLC?

Received a booklet in the mail (Enter the "Priority Code" printed in the lower left corner on the back cover of the booklet.):
Heard about the BLC at a Stephen Ministries training course or workshop
Heard about the BLC at another type of seminar or workshop
Someone told me about the BLC
Learned about the BLC on the Stephen Ministries Web site
I saw the DVD
Other (please specify):
Please sign me up to receive occasional e-mail updates about the Breakthrough Leadership Conference.