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

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

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 *

reCAPTCHA

Group Change Form

Old Information

Next Section – New Info

Final Section