New GSBAA Company Member / Delegate Form

Service Position(Required)

Company Member / Conference Delegate

Company Member / IG Secretary

Company Member / World Service Delegate

Provincial Intergroup(Required)

Leinster Intergroup

Munster Intergroup

Connaught Intergroup

Ulster Intergroup

Term Start Date(Required)

Term Finish Date

Contact Name(Required)

First Last

Address(Required)

Street Address Address Line 2 Town / City County Eircode

Phone(Required)

Official AA Mailbox Address(Required)

Name of the Company Member Being Replaced(Required)

First Last

Name of Approver - AA Trustee(Required)

First Last

Date Form Submitted(Required)