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

Public Agency Company & Sustaining Company Change Request Form

Company Administrators, please use this form anytime you wish to request changes to your company roster, such as add, remove or change information for an individual. If you have more than 5 individuals to add or remove, please submit multiple forms or email membership@imsasafety.org with the full name, email, phone number and title of the individuals.
Please allow 10 business days to process your request.

You will be notified by email from the IMSA membership team once changes are made to your roster and an invoice is ready in your account to pay if applicable.
These changes are for:*

2025 (I need these changes immediately for program registration)2026 (I need these changes before the renewal invoice)No rush (regular roster maintenance)
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
IMSA ID#
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
IMSA ID# (Person 2)
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
IMSA ID# (Person 3)
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
IMSA ID# (Person 4)
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
IMSA ID# (Person 5)
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 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 once changes are completed.

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

Public Agency Company & Sustaining Company Change Request Form

Thank you! We will be in touch once changes are completed.