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
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