BAN Coordinator Application

I would like to sign up to be a coordinator for: (City, State/Prov)

Email address for BAN (This email address will be posted on the List of Cities (Most Coordinators choose an address that reflects their city, etc. You can get a new Free e-mail account through Yahoo or Hotmail):

Your Full Name (required)

Your Personal Email (required)

Your Telephone Number (required)

Your Address (required)

Your City, State/Province (required)

Zip/Postal Code

Your Country (required)

Number of years I had been married when I learned of the affair:

Date I learned about my spouses affair:

My spouse and I have talked about it:
a littlea lot

We are:

I have discussed it with: (check all that apply)
A friendA family memberA counselor or professionalOtherNo one

I have read all of the pages of material posted about BAN (If not, please read everything before submitting this form):

Any other comments or questions?