Divine Mercy Image Request Form

I would like to be a Guardian and host a Visitation of the Divine Mercy Image. I have obtained my pastor’s permission and have obtained from him some possible dates for the Prayer Service. I understand that I need to form a Guardian Team to do this and to work in cooperation with our pastor to schedule and prepare the Visitation.

You may submit this form with a $25.00 credit card payment or send a check or money order to us. You may also call us at 802-524-5673 with credit card payment. Checks should be made payable to Missionary Image and sent to:

The Missionary Image
144 Sheldon Road
St Albans, VT 05478

* Required

Title

First Name *

Last Name *

Billing Address *

City *

State *

Zipcode/Postcode *

Country *

Home Phone Number *

Email Address *

Name of Parish

Name of Pastor

Pastor’s Telephone Number

Divine Mercy Image
I request a Divine Mercy Image
Our parish will provide its own Divine Mercy Image

{module_ccsecurity}

Payment Method *
Credit Card
PayPal

Enter Word Verification in box below *
{module_recaptcha}

Name on Card *

Card Number *

Card Expiry *

Card Type *

CCV Number *

Amount *

Dan Lynch Apostolates

OUR LADY OF GUADALUPE
Be Free From Worry, Fear and Anxiety

Divine Mercy Image Request Form

Dan Lynch Apostolates

OUR LADY OF GUADALUPE Be Free From Worry, Fear and Anxiety

Divine Mercy Image Request Form

OUR LADY OF GUADALUPE
Be Free From Worry, Fear and Anxiety