Co-Dependents Anonymous, Inc.

 PO Box 33577
Phoenix, AZ
85067-3577
(602) 277-7991

CoDA DELEGATE/ALTERNATE REGISTRATION FORM

Use this form for registering the two Delegates and/or two Alternates from your Voting Entity and for updating CoDA regarding changes.
PLEASE TYPE OR PRINT LEGIBLY

VOTING ENTITY REPRESENTED ____________________________

Please, if applicable, state whether a former Delegate or Alternate is being replaced.

1. Name of Delegate/Alternate Being Replaced:
Indicate if Delegate or Alternate:
2. Name of Delegate/Alternate Being Replaced:
Indicate if Delegate or Alternate:
3. Name of Delegate/Alternate Being Replaced:
Indicate if Delegate or Alternate:
4. Name of Delegate/Alternate Being Replaced:
Indicate if Delegate or Alternate:

CURRENT DELEGATE
As the Delegate representing your state, your first name, last initial, phone number, and e-mail  address 
may be appearing in CoDA National contact Directories. 
YOUR SIGNATURE IS REQUIRED FOR THIS INFORMATION TO BE RELEASED.

1. Current Delegate Name:
Address:
City: State: Zip:
E-Mail: Phone:
SIGN HERE PLEASE. I give my permission to list my name, phone number and e-mail address in the National Contact Directory.
  
2. Current Delegate Name:
Address:
City: State: Zip:
E-Mail: Phone:
SIGN HERE PLEASE. I give my permission to list my name, phone number and e-mail address in the National Contact Directory.
  
3. Current Alternate Name:
Address:
City: State: Zip:
E-Mail: Phone:
SIGN HERE PLEASE. I give my permission to list my name, phone number and e-mail address in the National Contact Directory.
  
4. Current Alternate Name:
Address:
City: State: Zip:
E-Mail: Phone:
SIGN HERE PLEASE. I give my permission to list my name, phone number and e-mail address in the National Contact Directory.
  

rev 01/2001