Organizational Member
Information Form
AOAC ID (if applicable)
Organization Information
Organization Name
*
Organization Type
*
Academic Institution
Association/Professional/Scientific Society
Consultant
Government - Local
Government - State/Provincial
Government - National or International
Independent Lab
Industry
Non-Governmental Organization
Retired
Other
Type of Roster Update
New
Remove
Replacement
Name of person you are removing/ replacing
Contact Information
for Individual to Add to Your Roster
Prefix
*
Dr.
Mr.
Ms.
Mrs.
Miss
First Name
*
Last Name
*
Job Title
Street Address
*
Suite/Room/Floor/Department
City
*
State
Postal Code
Country
*
Country
Phone Number
*
Fax Number
E-mail Address
*
example@example.com
Primary Representative
Check, If Applicable
Yes, I will be the primary representative for my organization
Account Type
Select One
*
Individual Member Representative (full membership benefits including OMA online)
Instructions (Example: Are you replacing a current person on the OM roster? If so, who?)
Submit
Should be Empty: