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Athenian
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IIMC Annual Conference
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IIMC Region XI Symposium Registration

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IIMC Contact Information Update Form for Current Members ONLY - No Payment - NOT FOR NEW MEMBERS - YOU DO NOT NEED TO CREATE AN ACCOUNT

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ID Number:*
First Name*
Last Name*
Job Title*
Work Phone Number*
Municipality*
State/Province*
Country
Email Address*
Which of the following do you need to update?*
1. I need to update my municipality information
2. I need to update my personal information.
Which of the following municipality information needs updated?
Check all that apply.
1. Name
2. Title
3. Municipality
4. Work Address
5. Work Telephone
6. Work Fax
7. Work Cell Telephone
8. Work Email Address
9. Web Address
10. Population
Which of the following personal contact information needs to be updated?
1. Name
2. Home Address
3. Home Phone
4. Personal Cell Phone
5. Home Email Address
New Municipality*
Municipality You Are Leaving*
Did you Replace Someone in your New Municipality?*
1. Yes
2. No
Please Enter Name of Replaced Employee*
Current Name on Membership*
Your New Name*
This is for name changes and not employee changes.
Title Change*
Work Address Change*
Work Telephone Change*
New Work Fax Number*
Web Address Change*
Home Address Change*
Home Telephone Change*
New Work Cell Number*
New Work Email *
New Personal Cell Number*
Population Change*
New Home Email*