AA Meeting Registration Form
Name of Defendant
First Name
Last Name
Name of Officer (If known)
First Name
Last Name
Group Name
Group Reference Number (if known)
Meeting Date and Time
Meeting Duration
Date of First Meeting in This Group
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address of Meeting
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was it an "open" meeting?
Yes
No
Please give details
Helpline Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
"Where to find" phone contact information
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Name 1
First Name
Last Name
Phone Number 1
Please enter a valid phone number.
Format: (000) 000-0000.
Name 2
First Name
Last Name
Phone Number 2
Please enter a valid phone number.
Format: (000) 000-0000.
Group Email Address
Not enter a personal email address since this will appear where to find.
Group Leader Name (If known)
First Name
Last Name
Additional Information
Signature of Defendant
Signature of Group Leader
Submit
Should be Empty: