Seminar Request Form

Attention All Organization Program Directors

“TAKING CARE OF GOD’S TEMPLE”

...is a unique seminar offering as part of Dr. Morris F. Keller's outreach program on health to help wake up and to revitalize people of faith in their walk with God.

Organization leaders, please fill out this request form as completely as possible to help us with our planning. Dr. Morris F. Keller and his wife, Rose, will be delighted to visit your synagogue, church, or organization community at the earliest opportunity that can be arranged.

Thank you for your interest.

This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in

Seminar Request Form

Please note that all fields followed by an asterisk must be filled in.

What is your title or role in the organization that you are representing?

First Name*

Last Name*

E-Mail Address*

Web Site URL

Street Address*

City*

State/Prov

Zip/Postal Code

Country*

Home Phone*

Business Phone*

Fax

Organization Information: Name, address, denomination, Sr. Pastor & Spouse's names, website and other contact information *

Please specify desired dates and times and the expected number in attendance*

If less than 500, can you combine with other organizations to sponser the meeting(s)?*

A Yes

B No

Are you willing to print and post announcements that we will provide you with?*

A Yes

B No

Do you have overhead projection capability for a Power Point Slide presentation?*

A Yes

B No

Do you have a chalk or writing board available on a stand or easel?*

A Yes

B No

What is the nearest commercial airport and driving distance to venue.*

Please enter the word that you see below.

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