APPOINTMENT REQUEST

* First Name: * Last Name: City: State / Province Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory * Phone: * Email: This form is to schedule an appointment/counseling or conference session with Pastor Dennis E. Thomas. Please complete the form below. Please be as specific as possible. Rest assured that your information will remain confidential. This form will go DIRECTLY to Pastor Thomas for review and scheduling. TYPE of MEETING * Reason for requesting to meet with Pastor Thomas Self Pre-Marital Counseling Couple/Marital Counseling Family/Group Meeting Auxiliary/Ministry Meeting Funeral Preparation OTHER (please indicate below) If you answered OTHER, please indicate reason for meeting below: * Indicate day(s) that best fit your schedule (choose ALL that apply) Mondays Tuesdays Thursdays * Indicate time of day which best fits your schedule to meet. 1:00 p.m. - 2:30 p.m. 2:30 p.m. - 4:30 p.m. 4:30 p.m. - 6:00 p.m. Any time is suitable * Can this issue be addressed via telephone/conference call? YES NO Any additional notes/requests?: * Indicates required entry field