ONTARIO SOUTH LDC			                                      C-6
P.O. Box 272
Keswick, Ontario L4P 3E2
Tel: (905) 989-0107     Fax (905) 989-0681  email: ldc@al-anon.alateen.on.ca 
ARE YOU WILLING TO HAVE YOUR NAME ON THE SPEAKER’S LIST AT THE ONTARIO SOUTH LDC?
IF SO TELL US ABOUT YOURSELF

Date: ___________________________

Full Name: ________________________________________

Address:  _________________________________________

Telephone number: ___________________ e-mail: _____________________________

Length of Time in Al-Anon: _________________________________________________

Where have you spoken?___________________________________________________

_________________________________________________________________________

At what level do you prefer to speak? ________________________________________

_________________________________________________________________________

Your Favorite Topics: ______________________________________________________

_________________________________________________________________________


Do you have transportation? ________________________________________________


Are you attending meetings regularly?________________________________________

Will you and your spouse speak as a team? ___________________________________

Will you and your family speak as a panel? ___________________________________