Group Registration/Change Form

Please read instructions before filling out this form.

If you prefer to print out this form and submit it by mail, there is a PDF* version.

Reason for Submission*

New Group Change Information Cancel Group

Effective Date:

Submitted by:*

Telephone#:* E-mail#:*

*Required

Group Number

NOTE: Always enter your group number unless yours is a new group. Enter the last five digits only. You can find your group number here.

Group Number:

Meeting Location

Meeting Place:

Street Address:

City: County:

State: Zip code:

Note:

Meeting Day, Time, Special Focus/Topic

Meeting Day: Meeting Time: AM PM

Special Focus/Topic:

Notes:

Meeting Contact Information

IMPORTANT NOTE: If you are the contact for your meeting, ONLY your first name and phone number will be listed on the Web site. Please select another contact person if you do not want to be listed online. Every group must have a contact person.

Primary Contact

First name only:

Telephone#:

E-mail address:

Alternate Contact

First name only:

Telephone#:

E-mail address:

Secretary/Permanent Mailing Address

NOTE: Full names and addresses are published ONLY within the Fellowship and will not appear online.

Full name:

Street address or PO Box:

City: State: Zip code:

Telephone#

E-mail address:

Intergroup Representation

NOTE: Full names and addresses are published ONLY within the Fellowship and will not appear online.

Primary Intergroup Representative

Full name:

Street address or PO Box:

City: State: Zip code:

Telephone#

E-mail address:

Alternate Intergroup Representative

Full name:

Street address or PO Box:

City: State: Zip code:

Telephone#

E-mail address:

Designated Downloader

First name and last initial:

E-mail address:

Cancel Group

State the reason you are canceling the group:

* PDF files require Acrobat Reader. If you do not have Acrobat installed on your computer, click on the icon below to download this free tool from the Adobe web site.