A.B.A.T.E. OF PENNSYLVANIA
CHANGE OF INFORMATION FORM

IMPORTANT:
All information changes will take place within 2 weeks of receipt. If current issue of "Between the Lines" is in production, changes will not take effect until the next issue.

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Effective Date: * (Type the date your NEW info will be in effect.)

(Select all that apply to you): *
A.B.A.T.E. of PA Member
A.B.A.T.E. of PA Officer
Other, please describe below.

OLD INFORMATION
Old Chapter:
*
Full Name:
*
Old Address:
*
Old Address 2:
Old City:
*
Old State:
*
Old Zip:
*
Old Phone:
* (include your area code) ex. xxx-xxx-xxxx
Old Email:
NEW INFORMATION
New Chapter:
*
Full Name:
*
New Address:
*
New Address 2:
New City:
*
New State:
*
New Zip:
*
New Phone:
* (include your area code) ex. xxx-xxx-xxxx
New Email:
*

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