Group Information Change Form

Group Information Change Form

Area 59, Panel 71
Date *

Month Day Year
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
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
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:

Group Information Change Form

Old Group Information

Old General Service Representative (GSR)

Old Alternate General Service Representative (AGSR)

New Group Information

New Mail Contact and/or General Service Representative (GSR)

New Alternate General Service Representative (AGSR)