Form – New Affiliate Signup – Amen: The Prayer App

First Name *

Last Name *

Organization *

Industry

What is your industry, or organization category?

Group Code *

Choose a simple name that identifies your group with no spaces. Example: firstbaptist or WXYZ

Website / URL *

http:// or https:// required

E-mail *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about Amen? *

Approximately how big is your prayer community?

What else would you like us to know, or what questions can we answer for you?