IMSA Public Agency and Sustaining Members - Add, Remove, Update Company Roster Form (NEW)

Public Agency Company & Sustaining IMSA Members Only

Add, remove or change information on an employee on your company roster form. If you have more than 5 individuals to add/remove, you may email membership@imsasafety.org with the full name, email, phone number and title of the individuals.
Please complete this form anytime you wish to make any changes to your company roster.

You will be notified by IMSA membership team once changes are made to your roster and an invoice is ready in your account to pay.
Please allow 5 business days to process your request.
Who is filling this form out?*

First NameLast Name
Name of Public Agency/Organization/Business*
What is your email address?*
IMSA Company ID#
If known
What is your phone number in case we have questions?
Are you the current Company Administrator?*

YesNo
New/Existing Member Information Only
I want to:*
Name*

First NameMiddle NameLast NameSuffix
Date of Death
Retirement Date
Job Title*
Email Address *
Work address (if different than your address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number*
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email
example@example.com
Personal Phone number
Do you want to add or remove another person?*
I want to: (Person 2)*
Name (Person 2 )*

First NameMiddle NameLast NameSuffix
Date of Death (Person 2)
Retirement Date (Person 2)
Job Title (Person 2)*
Email Address (Person 2) *
Work address (if different than your address) (Person 2)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number (Person 2)
Home Address (Person 2)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email (Person 2)
example@example.com
Personal Phone number (Person 2)
Do you want to add or remove another person?*
I want to: (Person 3)*
Name (Person 3 )*

First NameMiddle NameLast NameSuffix
Date of Death (Person 3)
Retirement Date (Person 3)
Job Title (Person 3)*
Email Address (Person 3) *
Work address (if different than your address) (Person 3)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number (Person 3)
Home Address (Person 3)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email (Person 3)
example@example.com
Personal Phone number (Person 3)
Do you want to add or remove another person? *
I want to: (Person 4)*
Name (Person 4)*

First NameMiddle NameLast NameSuffix
Date of Death (Person 4)
Retirement Date (Person 4)
Job Title (Person 4)*
Email Address (Person 4) *
Work address (if different than your address) (Person 4)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number (Person 4)
Home Address (Person 4)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email (Person 4)
example@example.com
Personal Phone number (Person 4)
Do you want to add or remove another person?*
I want to: (Person 5)*
Name (Person 5)*

First NameMiddle NameLast NameSuffix
Date of Death (Person 5)
Retirement Date (Person 5)
Job Title (Person 5)*
Email Address (Person 5) *
Work address (if different than your address) (Person 5)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number (Person 5)
Home Address (Person 5)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email (Person 5)
example@example.com
Personal Phone number (Person 5)
Comments: Please add any existing IMSA ID#s or notes here
Only the company administrator is authorized to make changes to the company roster and membership. If changes need to be made to the company administrator, or for any other questions/concerns, please contact membership@imsasafety.org
Thank you! We will be in touch shortly.

Questions, please email membership@imsasafety.org
Should be Empty:

Public Agency Company & Sustaining IMSA Members Only

Please complete this form anytime you wish to make any changes to your company roster.

Thank you! We will be in touch shortly.