___ New Subscription
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___ Renew Subscription
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Billing Address:
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Full Name or Facility Name: _______________________________________________________
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Address: _______________________________________________________________________
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City,State and Zip: ______________________________________________________________
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Phone: ____________________ *E-mail: __________________________________________
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This is a gift from: ________________________________________________________________
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Credit to Lifeline Representatives: ____________________________________________________
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Shipping Address (magazine will be sent to this address):
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This address is the same as my billing address. If different, complete fields below. If you change something on the form above, you must check this button again or your change won't be recorded below.
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Full Name or Facility Name: ____________________________________________________________________
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Mailing Address: ______________________________________________________________________________
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City, State and Zip: ____________________________________________________________________________
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Length of Subscription: _____ 1 Year _____ 2 Year _____ 3 Year
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___ Yes, I want to be a Lifeline Rep and promote Lifeline magazine.
Put me on the Rep list and send me a Rep Kit.
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___ Renew me as a Lifeline Rep.
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___ Delete me from the Rep List.
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Lifeline Challenge participants must include the following information.
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Group Number: __________________
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Name of Group Contact: ____________________________________________________________________
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Group Location: ___________________________________________________________________________
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Meeting Day and Time: _____________________________________________________________________
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Group Contact Address: _____________________________________________________________________
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City, State, and Zip: _________________________________________________________________________
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If you wish to pay by check or money order, complete this order form, print it, enclose with check made payable to
World Service Office
and mail to:
World Service Office
P.O. Box 44020
Rio Rancho, NM 87174-4020 USA
If you have questions or concerns about your order, contact the WSO by calling 505-891-2664 or e-mail to info@oa.org.
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