AMIAS Recertification Request
This is ONLY for Current AMIAS's. After completing both pages of this form, be sure to push the "Submit" button on the bottom of the second page. We use this form submission software because it works, however our use is not an endorsement of it.
Submission Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number - Mobile
-
Area Code
Phone Number
Phone Number - Home
-
Area Code
Phone Number
E-mail
example@example.com
Primary Alateen group you participate with
District of the Meeting (if known)
Back
Next
Attestation
By typing my name below, I certify that:
By typing your name below, you are certifying that you agree with the above statements and that they are true.
First Name
Last Name
Submit
Should be Empty: