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Moved recently?
Have a new phone number or e-mail address?
If any of your contact information has changed, we'd love to know.
That way we can communicate more quickly and efficiently with you.

Please fill in the required fields* before submitting this form
(those with an asterisk*).

Thank you!

Old address/information:

*First Name  
*Last Name  
*Previous Address  
*Previous City  
*Previous Zip  
Previous Home Phone
Previous Work Phone
Previous Cell Phone
Previous E-mail

New address/information:

*New information
as of this date:		  
 
*Current First Name  
*Current Last Name  
Spouse's First Name
Spouse's Last Name
Children Living With You
Please list first name,
last name, and
date of birth for each.
*Current Address  
Current City
*Current Zip  
*Current Home Phone  
 Current Work Phone
Current E-mail
Spouse's Work Phone
Spouse's Cell Phone
Spouse's Email
Comments/Questions

 

Indianola Community Church
Phone 515.961.8311  · Fax:  515.961.0309
Email:  icc@indianolacc.org
14424 Kennedy Street · Indianola, IA  50125
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