Change of Contact Information Form

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

LEA membership number (optional)

Enter the date this change is effective.

-- mm/dd/yy

Enter name change

Name

New e-mail address

E-mail

New address

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

New telephone number

Work Phone
Home Phone

Please provide name of new ministry location

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Preferred e-mail address

E-mail

Preferred postal address

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Membership type

Individual member Husband-wife Retired Retired husband-wife Student

In which LEA Networks do you wish to participate?

Directors of Christian Education Network (DCEnet)
Early Childhood Educators Network (ECEnet)
Elementary Teachers Network (ETnet)
Leadership Network (LEADnet)
Mission & Outreach Network (MOnet)
Retired Educators Network (EncourAGEnet)
Secondary Educators Network (SECnet)