Member Information Form

If you are a member of Board 12, please use this form to add, update or change your contact information.

* Indicates required field

Your Name *

First

Last

Email *

Primary Board (i.e. 12) *

Year You Joined Board 12 *

Dual Board *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Work Phone Number *

Cell Phone Number *

Comment (if necessary) *

Submit