SENY – AREA 49

GRAPEVINE/LA VIÑA REPRESENTATIVE

REGISTRATION FORM

Please give as much information as you can.

Date:_______________________

Name of Group (or County or District)

for which you are the GvR/RLV:

___________________________________________

Location

Street/P.O. Box:

___________________________________________

City:

___________________________________,

New York

Zip Code:

___________

County:________________________

District Number:

___________

Group Number:__________________

Your Name (First and Last):

___________________________________________

Address:

___________________________________________

City:

_________________________

State: ____________

Zip Code:

_________________________

Telephone:

(

)____________________

eMail:

_________________________

Name of former GvR/RLV:

___________________________________________

(if known)

Please return this completed form to:

General Service Conference Committee/Southeastern New York

Grapevine/La Viña Committee Chair

PO Box 571

New York, NY 10116

NOTE:

If

you

register

with

SENY,

the

information

will

be

forwarded

to

the

Grapevine/La

Viña

Office, New York City.

If

you

register(ed)

with

the

Grapevine

Office/La

Viña

Office,

please

register

with

SENY

too.

Thanks!

World Wide Web Edition

1/1

02/24/08