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Please give your Email address in the first box, (below).
If you do not have an Email address your first name only will do.
Please enter your telephone number in the second box.
Your email address and phone number (box one and two) are requested for contact purposes in case we have questions about your entries.
For mailing purposes, we need your full name in the third box.
Enter your street address in the fourth box (Please do not forget Apt number if you have one.)
And finally, your city and zip code in the fifth box.
You may enter your Home Group and Sobriety Date if you desire in the box six, or other information you wish to send.
Please submit only one request
This information is for our Central Office records and is valuable for Twelfth Step purposes.
It will be safeguarded with the strictest confidence.
Please check your entries, then click the Submit button at the bottom of the form.
All items with an asterisk are required (exception is the Additional Info box).
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