NAME

ADDRESS

POSTCODE /ZIP CODE

CITY

TELEPHONE

MOBILE / GSM

EMAIL

CHURCH

FUNCTION

GROUP

NUMBER OF PEOPLE

LEADER (NAME)

23/24 November - Charleroi

GLS 2012

30 Nov/1 Dec. - Haacht

Payment

Account number Willow Creek be

IBAN: BE82 7340 1764 0568  BIC:  KREDBEBB

Reference: GLS 2012 + name

FIRST NAME

Registration is effective only after receipt of payment.