If you wish to modify the registration information, please re-enter all applicable fields even if 
they are not changed. Any data fields that are not filled in will be deleted from the file. 
The exception is the field for Primary activity. If you keep this field blank, we will transfer the 
original description to the modified registration file. (It may take a few days to make this transfer.)

All fields labeled in red must be entered, otherwise the form will not be accepted.

Organization Name:
Federal Tax ID:   Years as 501(c):
Address 1:          
Address 2:
City:
State:   Zip Code: (12345-6789)

Name of Primary Contact:
Title:
Phone Number: (123) 456-7890
Extension Number:
Fax Number: (123) 456-7890
E-Mail Address:

Name of Alternate Contact:
Title:
Phone Number: (123) 456-7890
Extension Number:
Fax Number: (123) 456-7890
E-Mail Address:

         Primary Activities of Your Organization: 
         (For a proper format, be sure to press "Enter" at the end of each line.)     
 

           Date Modified: (mm/dd/yyyy)

                                       

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Revised on April 7, 2000