Intergroup Number*: Enter zero for new intergroups. Region Number*: Virtual01020304050607080910
New GroupChange InformationCancel Group
First Name*: Last Name*: Email*: Phone Number*: Effective Date*:
Name*: Do you belong to a national/language service board (N/LSB)? YesNo
If Yes:
N/LSB Name: N/LSB Number: Region Number: Virtual01020304050607080910 If you wish to change National/Language Service Board affiliation, list your new affiliation below: New N/LSB Name: New N/LSB Number: New Region Number: Virtual01020304050607080910
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.
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