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
Name
*
First Name
Last Name or Initial
Date Elected
*
-
Month
-
Day
Year
Date
Group Name
*
District Number
*
Don't know your district number?
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Position (Committee)
*
Are you an Alternate?
*
Yes
No
You will receive a Digital GSR 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
Should be Empty: