| *Your E-mail Address: |
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| *Your Name: |
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| Contact Telephone No's: |
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Contact Phone Number |
International Code
Area Code
No
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Fax Number |
International Code
Area Code
No
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Mobile Number |
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| Is this application for a |
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| Name of Group |
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| Street Address of where group meets |
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Suburb where they meet:
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| Town where they meet: |
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| Nearest Large Town to where they meet: |
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| Province/State in which they meet: |
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| Country of Group: |
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| Days on which the group meets: |
Mon
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Tue
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Wed
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Thurs
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Frid
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Sat
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Sun
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| Times that group meets in Hrs: e.g. 16:00 hrs for 4PM |
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| Days of the Week/Month when group meets: |
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| Group meets on a particular day number of each month |
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| How long has the group been in operating |
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| Do you provide Support for: |
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| Is your group for: |
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| Name of Coordinator/ Facilitator/ Leader of group: |
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| Our Coordinator/Leader/Facilitator is a: |
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| Is your group affiliated to any organization/s: |
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| List your web site address if available |
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| Any info. that you would like to share |
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