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Serving 8 Midwestern States, 2 Canadian Provinces and 1 Territory

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R4 Business
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R4 Intergroups
OA Beyond R4

About
R4 Business
Events in R4
R4 Intergroups
OA Beyond R4

Multiple R4 Region Representatives Assembly Registration

Name *

Email *

Subject *

Message

Intergroup Name *

WSO Number *

Intergroup Address

Include city, state/province, zip/postal code

Intergroup Phone Number *

Number of Groups *

One rep for every ten (10) groups or portion there of.

Number of Representatives Allowed *

First Rep Name *

First Rep Address *

Include city, state/province, zip/postal code

First Rep Phone Number *

First Rep Email *

First Rep Status *

Representative
Alternate

First Rep Term Expires *

All representatives are asked to choose one committee on which to serve for until the following Assembly. First Rep Committee Choice

Convention
Outreach
Ways & Means/Finance

Second Rep Name *

Second Rep Address *

Include city, state/province, zip/postal code

Second Rep Phone Number *

Second Rep Email *

Second Rep Status *

Representative
Alternate

Second Rep Term Expires *

All representatives are asked to choose one committee on which to serve for until the following Assembly. Second Rep Committee Choice

Convention
Outreach
Ways & Means/Finance

Third Rep Name *

Third Rep Address *

Include city, state/province, zip/postal code

Third Rep Phone Number *

Third Rep Email *

Third Rep Status *

Representative
Alternate

Third Rep Term Expires *

All representatives are asked to choose one committee on which to serve for until the following Assembly. Third Rep Committee Choice

Convention
Outreach
Ways & Means/Finance

Fourth Rep Name *

Fourth Rep Address *

Include city, state/province, zip/postal code

Fourth Rep Phone Number *

Fourth Rep Email *

Fourth Rep Status *

Representative
Alternate

Fourth Rep Term Expires *

All representatives are asked to choose one committee on which to serve for until the following Assembly. Fourth Rep Committee Choice

Convention
Outreach
Ways & Means/Finance

First Assembly *

First Rep
Second Rep
Third Rep
Fourth Rep
None of the above

Willing to mentor a new rep *

First Rep
Second Rep
Third Rep
Fourth Rep
None of the above

Intergroup Chair Name *

Intergroup Chair Email *

Acknowledgement *

I certify that the Representatives listed have at least six months current abstinence.

Region 4

2355 Fairview Avenue N
PMB 338
Roseville, MN 55113

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87174-4727
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