Join the 12 Step House & Participate in Your Recovery

Name:
Email:
Address:
Apt/Unit Number:
City:
State:
Zip:
Best time to call:
Phone:
Sober Date:
Grouup Affiliation:
Special Interests:

I WOULD BE INTERESTED IN HELPING
ON THE FOLLOWING COMMITTEES: :

 
I HAVE READ, UNDERSTOOD AND AGREE TO ABIDE
BYTHE HOUSE RULES OF THE TWELVE STEP HOUSE, INC.
Signature:
   
RECCOMENDED FOR MEMBERSHIP BY: