Intergroup Registration / Change Form

Intergroup Number*:

Region Number*:
Virtual010203050607080910

New GroupChange InformationCancel Group

First Name*: Last Name*: Email*: Phone Number*: Effective Date*:

Name*: Do you belong to a national service board (NSB)?YesNo

If Yes:

NSB Name: NSB Number: Region Number:
Virtual010203050607080910 If you wish to change National Service Board affiliation, list your new affiliation below:New NSB Name: New NSB Number: New Region Number:
Virtual010203050607080910

Note: For anonymity purposes, please provide a generic email address.

Website Address:

Please include the country code (if outside US/Canada), city/area code and telephone number.

Answering Service: Alternate:

Name*: Phone Number*: Email*: Name*: Phone Number*: Email*:

Please enter numbers and cities, state/province (if in US/Canada) and country of all groups affiliated with your intergroup.