Area Service Committee Registration Form

Please complete all information & print clearly!

Committee is in which Region? / Date
Committee was formed in month/year? / Annual elections are held in which month?
How many groups? / Meetings?
Is this Area serviced by a Metropolitan Service Committee? Yes / No (circle one)
If yes, MSC name
Which subcommittees are administered by this MSC?

Area Committee Mailing Address

Committee Name:
Address/PO Box
City / State/Prov / Zip/Postal
Country / Web page URL address
Area Helpline Number ( ) / Helpline is based in what city?

Trusted Servants Mailing Addresses

Area Service Contact [ ] position vacant / Area Office Address (if applicable)
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email
[ ] Yes, send me the NA Way Magazine / Contact Person
RCM [ ] position vacant / RCM [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Activities Contact [ ] position vacant / Convention Contact [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

(over)

H&I Contact [ ] position vacant / Literature Distribution Contact [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Literature Review Contact [ ] position vacant / Meeting List Contact [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Newsletter Contact [ ] position vacant / Phoneline Contact [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Phoneline Contact [ ] position vacant / PI Contact [ ] position vacant
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Webpage Contact [ ] position vacant / ______(position)
Name / Name
Address / Address
City / St/Prov / City / St/Prov
Zip/Postal / Country / Zip/Postal / Country
Phone ( ) / Phone ( )
Email / Email

[ ] Yes, send me the NA Way Magazine[ ] Yes, send me the NA Way Magazine

Feel free to duplicate and distribute this form

PLEASE RETURN THIS TO: NAWorld Services, Inc., PO Box 9999, Van Nuys, CA 91409-9099 USA

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