Group Information Change Form

Group Information Change Form

Area 59, Panel 69
Date *

Month Day Year Date Picker Icon
Group Service Number
District # *
Delegate Area # *
# Members
Old Group Information
Old Group Name *
Old Meeting Facility *

Old Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Old Facility Phone
Old Meeting Day

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Monday Times
Tuesday Times
Wednesday Times
Thursday Times
Friday Times
Saturday Times
Sunday Times
Old General Service Representative (GSR)
Old GSR Name

First Name Last Name

Old GSR Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Old GSR Phone

Area Code Phone Number
Old GSR E-mail
Old Alternate General Service Representative (AGSR)
Old AGSR Name

First Name Last Name

Old Alt-GSR Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
E-mail
New Group Information
New Group Name *
New Meeting Facility *

New Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New Facility Phone
New Meeting Days

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Monday Times
Tuesday Times
Wednesday Times
Thursday Times
Friday Times
Saturday Times
Sunday Times
New Mail Contact and/or General Service Representative (GSR)
Mail Contact

First Name Last Name
Email
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New GSR Name

First Name Last Name

New GSR Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New GSR Phone

Area Code Phone Number
New GSR E-mail
OK to list New GSR in Directory

Yes No
New Alternate General Service Representative (AGSR)
New AGSR Name

First Name Last Name

New AGSR Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

New AGSR Phone

Area Code Phone Number
New AGSR E-mail
OK to list New AGSR in Directory?

Yes No
Submitted By *
Submitter E-mail *
This form will be sent to the Area 59 Officer At Large upon completion and submission.
Should be Empty: