Delegate Signup Form

NICA DELEGATE SIGN-UP

Registration for Group and Intergroup Delegates
Register as a Nicotine Anonymous Delegate

Every registered NicA group/meeting may select a delegate who will be given voting rights at the World Services Conference (WSC). Additionally, registered Intergroups may select one delegate. In addition to carrying the group’s conscience to the WSC, a delegate also assumes the responsibility of keeping their group informed of activities and news related to the fellowship of NicA as a whole. If you have questions about this form, contact secretary-emeritus@nicotine-anonymous.org.
NAME*

First NameLast Name
DATE ELECTED*

MonthDayYear
Date
GROUP NAME
Provide the name of your group you are representing. Groups must be registered with Nicotine-Anonymous.org through https://www.nicotine-anonymous.org/add-a-meeting
MEETING DAY/TIME/ZONE
When your group meets: day of the week, local time and time zone
INTERGROUP NAME
If you're representing an intergroup, provide the name of registered Intergroup.
ATTENDING CONFERENCE ONLINE OR IN-PERSON?*
Will you attend online or in-person? Before the conference, you can change how you will attend, simply contact Secretary-Emeritus@nicotine-anonymous.org.
EMAIL:*
example@example.com.
Address*

Street Address.

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Should be Empty:

NICA DELEGATE SIGN-UP