Please complete this form to register for the monthly anniversary meeting. All fields are required. Click the submit button once. (You will be celebrating the month following your anniversary month.)
Your name
*
First Name
Last Name or Initial
Your email address
*
Would you like you anniversary coin mailed? (US only)
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Sobriety Date
*
-
Month
-
Day
Year
Date Picker Icon
Number of years you're celebrating
*
Who will be presenting you with your coin?
*
First Name
Last Name or Initial
Submit
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