Bereavement Submission

Area 12 Member Name Submitting This Item *

First

Last

Your First Name and Initial of your Last Name

What is your Home Group / Room *

The Group name or room member completing the Bereavement announcement

Are you A GA member or not a GA member? Please choose 1 *

Your Email Address *

Name of Area 12 GA member to be memorialized *

First

Last

GA Member First Name and Initial of their Last Name

Rooms / Groups attended by the member *

Multiple selections allowed, for multiple selections click and hold the Ctrl button and click on the mouse

Last Abstinence Date / Years of Abstinence / Unknown

If known please enter Gamblers Anonymous Anniversary Date, or number of Anniversary years.

Date of Passing

Comments / Additional Information

Phone