ALCOHOLICS ANONYMOUS, INDIA MEMBERSHIP SURVEY FORM

“Our membership ought to include all who suffer from alcoholism. Hence we may refuse none
who wish to recover. Nor ought AA membership ever depend upon money or conformity. Any two
or three alcoholics gathered together for sobriety may call themselves an AA group, provided
that, as a group they have no other affiliation” - Tradition Three (long form)

Name: ______________________________________________________________________

Home Group: ________________________________________________________________

Inter Group ____________________ City ____________ State _____________

Continuous Sobriety: 1 – 3 years, _____ 3 – 5 years, ______ 5 – 10 years __________

10 – 15 years, _____15 – 20 years,______ above 20 years ________

Age: ______________ Gender: Male_____ Female _________

Do you have sponsor?: Yes _______ No: _______

Message received through: Rehab.________________ Hospital _____________

Pvt. Treatment Facility ____________Person _______________
Print Media ________________ Electronic Media ___________

Profile of member: Pvt. Service. _____________ Public Service __________________

Professional__________________ Other Business _________________

Service positions held. _______________________________________________________

_____________________________________________________________

____________________________________________________________

Any other information you would like to furnish: ____________________________

______________________________________________________________________________

Would like to serve on: Treatment Facility Committee _____________________

P.I. Committee ___________________________________
As Volunteer ____________________________________
In any other capacity ______________________________

This information is collected to prepare Membership Survey of India. This

information will be strictly confidential and will not be parted to anyone.

Name: Signature.

PLEASE RETURN TO: GSO (I), P.O. BOX 16958, BYCULLA, MUMBAI - 40027