NHAA DISTRICT 12
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Group Change Form
Group Service #
*
Area 43 District #
*
Today’s Date
*
Number of Members
Old Information
Group Name
*
Group Meeting Location
*
Street Address
*
City/Town
*
State
*
Zip
*
Meeting Day(s)
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
General Service Rep (GSR) Name
*
Street Address
*
City/Town
*
State
*
Zip
*
Phone
*
Email
*
Alternate GSR or Contact Person Name
Street Address
City/Town
State
Zip
Phone
Email
Next Section – New Info
Part II: Group Name
*
Group Meeting Location
*
Street Address
*
City/Town
*
State
*
Zip
*
Meeting Day(s)
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
General Service Rep (GSR) Name
*
Street Address
*
City/Town
*
State
*
Zip
*
Phone
*
Email
*
Alternate GSR or Contact Person Name
Street Address
City/Town
State
Zip
Phone
Email
Final Section
Meeting Type
*
C – Closed
X – Step
Z – Address Clarified
F – French Speaking
S – Speaker
B – Big Book
H – Handicap Access
& – Spanish Speaking
D – Discussion
G – Gay/Lesbian
+ – Hearing Impaired
* – Al-Anon same time & place
Option 14
Listing in the Eastern States Directory is for 12th Step Referral and/or requests for meeting informational
*
Yes
No
The GSR’s (or other contact) full name and telephone number will be included with the group’s name and service number. Is it ok to list in the directory? Groups without a phone number will NOT be in the directory.
Name of Person Submitting this Group Change Form
*
Phone
*
Email
*
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