CHANGE OF NAME/ADDRESS FORM

CHANGE OF NAME/ADDRESS FORM
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_____________________________
THE IZAAK WALTON LEAGUE OF AMERICA, INC.
NATIONAL OFFICE
DATE
DIVISION AND CHAPTER NUMBER
707 Conservation Lane, Gaithersburg, MD 20878-2983
CHAPTER NAME
1-800-IKE-LINE l 301-548-0150 l Web: www.iwla.org
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NAME AND TITLE OF OFFICER
DAYTIME PHONE NUMBER
________________________________________________________
EMAIL ADDRESS
SEND THE WHITE AND YELLOW COPIES TO THE NATIONAL OFFICE.
RETAIN THE PINK COPIES FOR YOUR CHAPTER RECORDS.
OLD NAME/ADDRESS
NEW NAME/ADDRESS
MEMBER ID #: __________________________
JUST RECORD
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NAME
________________________________________________________
NAME
__________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
__________________________________________________________
CITY, STATE, ZIP
________________________________________________________
CITY, STATE, ZIP
__________________________________________________________
PHONE NUMBERS (HOME/WORK)
________________________________________________________
PHONE NUMBERS (HOME/WORK)
__________________________________________________________
FAX, E-MAIL
________________________________________________________
FAX, E-MAIL
OLD NAME/ADDRESS
NEW NAME/ADDRESS
MEMBER ID #: __________________________
JUST RECORD
__________________________________________________________
NAME
________________________________________________________
NAME
__________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
__________________________________________________________
CITY, STATE, ZIP
________________________________________________________
CITY, STATE, ZIP
__________________________________________________________
PHONE NUMBERS (HOME/WORK)
________________________________________________________
PHONE NUMBERS (HOME/WORK)
__________________________________________________________
FAX, E-MAIL
________________________________________________________
FAX, E-MAIL
OLD NAME/ADDRESS
NEW NAME/ADDRESS
MEMBER ID #: __________________________
JUST RECORD
__________________________________________________________
NAME
________________________________________________________
NAME
__________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
________________________________________________________
ADDRESS (STREET, APT., P.O. BOX)
__________________________________________________________
CITY, STATE, ZIP
________________________________________________________
CITY, STATE, ZIP
__________________________________________________________
PHONE NUMBERS (HOME/WORK)
________________________________________________________
PHONE NUMBERS (HOME/WORK)
__________________________________________________________
FAX, E-MAIL
________________________________________________________
FAX, E-MAIL
CHANGED PORTIONS OF NAME OR ADDRESS
CHANGED PORTIONS OF NAME OR ADDRESS
CHANGED PORTIONS OF NAME OR ADDRESS
Revised 9/09