ACT Member Contact Information Change Form


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ACT Member Contact Information Change Form

If you are currently an APAGS-ACT Campus Representative, State Advocacy Coordinator, or Regional Advocacy Coordinator, you can use this form to notify ACT that your contact information has changed. IMPORTANT NOTE: The data in this form is only sent to relevant ACT Officers. This form does NOT notify the APA organization that your contact information has changed! To alert APA to changes in your contact information, you should contact the Membership Office via e-mail, or by phone at (800) 374-2721. Sorry for the hassle - We are working on a solution to this problem.

--- Required fields are in bold red letters, and are marked with an * ---

Your APA Member Number:

* If you are unsure of your Member Number, you can verify it with the Membership Office at
(800) 374-2721:

Your ACT status:

	Regional Advocacy Coordinator
	State Advocacy Coordinator
	Campus Representative

Your name:

* First Name:
Middle Initial:
* Last Name:
Suffix:

If your name has changed, please provide your new name:

First Name:
Middle Initial:
Last Name:
Suffix:

Your new address:
Street 1:
Street 2:
City:
* State:
Zip Code:
Four-digit zip extension (Optional):

Your new e-mail address:
Please verify accuracy:
Your new phone numbers:
Work or School:	() -
Home:	() -
The school you will represent:
(e.g., University of Akron):
The psychology program you will represent:
(e.g., Industrial Psychology):

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American Psychological Association of Graduate Students (APAGS)
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Telephone: 202-336-6014 • Email
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