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?