REQUEST for MEMBERSHIP MODIFICATION

ASC Z97 Representative Change Request

Please change the following status/membership classification of my ASC Z97 listing.

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* Company currently listed as:

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* Primary Representative currently listed as:

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* Membership Type:

Organization

Individual

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* Voting Rights:

Full Voting

Correspondence (Observer)

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* Reason for change:

Primary or Alternate left company

Primary or Alternate responsibility change

Address or location change

Affiliation/Disclosure change or update

Other (please specify)

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* Please complete the fields below to reflect the new, modified listing for the PRIMARY REPRESENTATIVE.

Primary Rep Name

Company Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* Please complete the fields below to reflect the new, modified listing for the ALTERNATE REPRESENTATIVE.

Alternate Rep Name

Company Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* Membership Type:

Organization

Individual

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* Voting Rights:

Full Voting

Correspondence (Observer)