WSO Group # _______________________________________________________

Group Name_________________________________________________________

Meeting Day and Time________________________________________________

Meeting Place________________________________________________________

Name: ______________________________________________________________

Phone: ______________________________________________________________

E-Mail: _____________________________________________________________

Address: ____________________________________________________________

_________________________________________________________________

City __________________________________ State ___________ Zip __________

 

Amount Enclosed _______________________________

Please make check payable to:    Region III OA

Send to:

Juda Smith (405) 737-7488
10517 Goldenrod Lane
Midwest City, OK 73130

Thanks!