Corrections and Treatment Facilities Committee Chairperson Nomination

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Date*

Nomination*

I nominate myself for the position

I nominate someone else for the position

Name*

First Last

Phone*

Email*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Home Group*

Sobriety Date*

Home Group service experience*

New York Inter-Group experience*

Other A.A. General Service experience*

Additional Qualifications*