Trusted Servant Registration/Update Form
Update or Register DCM's, GSR's, DCC's and Alternates
I would like to register or update information for
*
Please Select
General Service Representative or Alternate
District Committee Member or Alternate
District Committee Chair or Alternate
Mail Contact
Group Name
Language
Please Select
English
French
Spanish
Name of Trusted Servant to be Registered
*
First Name
Last Name or Initial
Are you registering yourself?
*
Yes
No, I'm submitting this registration on behalf of the above person
Sender Name
First Name
Last Initial
Sender Email
example@example.com
Position Effective Date
*
-
Month
-
Day
Year
Date
Group Name
*
District Number
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Email
*
example@example.com
Position Email (if different from above)
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Position (Committee)
*
Are you an Alternate?
*
Yes
No
If you are a GSR you will receive a Digital GSR Kit via Email. Do you require a physical kit mailed to you also?
*
Yes
No
If you are a DCM you will receive a Digital DCM Kit via Email. Do you require a physical kit mailed to you also?
*
Yes
No
Do you wish to be subscribed to the Area 79 contact list?
*
Yes
No
Submit
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