Private Coaching

Anne Bercht, author
"My Husband's Affair Became the Best Thing That Happened to Me"

Coordinators Sign Up Form

To volunteer to be a Local BAN Coordinator - Please fill in all the boxes below.
(Before volunteering, please read all the information about BAN posted on the website.)

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): *
Personal Email Address: *
First Name: *
Last Name: *
Phone Number: *
Street Address: *
City, State / Province: *
Zip / Postal Code: *
Country: *
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 little A lot
We are: *	Married Separated Divorced
I have discussed it with: (check all that apply): *
A friend A family member A counselor or professional Other No one
I have read all of the pages of material posted about BAN (If not, please read everything before submitting this form): *	Yes No
E-mail Address: *
Any other comments or questions?


Verification Code:
Enter Verification Code: *


* Required

Passionate Life Seminars
Canadian Office: Vancouver, BC 3499 Applewood Drive Abbotsford, BC V3G 3G3 Canada Ph: (604) 859-9393 Fx: (604) 859-9323	USA Office: Tampa, Florida 1374 Playmoor Drive Palm Harbor, FL 34683 USA Ph: (727) 935-4812 Fx: (727) 935-4085
Questions or comments about this web page? E-mail us at: info@beyondaffairs.com