Name: ________________________________________________________________________

Address: _____________________________________________________________________


Phone:   _________________________      Email: _______________________________

 1. Do you consider yourself a born-again Christian? _________________________

 2. Can you supply a letter of recommendation from your home church? _________

 3. What prison will you be taking the program to? ___________________________

    Address: _________________________________________________________________

 4. What security requirements are needed at this prison: minimum or maximum?


 5. Have you contacted the chaplain of this prison? ________

    Do you have his support? ________

 6. Is there presently an AA or NA meeting in this prison? ___________________

 7. Will you be taking our 12-step literature and workbooks to the prison

    weekly? __________________________________________________________________

 8. Have you ever had a felony conviction? ______ If so, what is your parole

    status? __________________________________________________________________

 9. If approved, when do you plan on starting A/C meetings? (Day and time)


10. Will you have any assistance in leading the meetings? ____________________


11. Are you willing to promote the need for prisoners to attend meetings after

    their release?____________________________________________________________

12. Are you a recovering alcoholic?________ If so, please explain: ___________



    __________________________________________     ___________________________
    Signature:                                     Date:

    Send to: A/C Prison Ministry, 1316 N. Campbell Road, Royal Oak, MI 48067


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