LVA Informational Change Form

Use this to immediately notify LVA, Inc. of any change(s) in your affiliate status or information. Please provide only one mailing address and one shipping address (if necessary).


Fill in the blanks below:

* Required Fields
*Person Submitting Change(s)
*Title
*Date of Change(s)
I am making changes to: (check all that apply)
Affiliate name Director name Mailing address Phone/Fax E-mail/Website EIN Shipping address
Informational Change(s)
*Affiliate Name
*Director Name
*Mailing Address
*City
*State
*ZIP Code
*Phone Number
*Fax Number
*E-mail
Website
Password for LVA Website Needed? Yes
EIN# Change

Shipping Address
If your affiliates's address contains a P.O. Box, you need to fill out the "shipping address" portion of this form so our shipping department can properly direct UPS shipments. UPS will not deliver to a P.O. Box. Due to space limitations, only your mailing address will be printed in the LVA Affiliate Directory.

Shipping Address
City
State
Zip Code