Change of Information Form

Your Current Personal Details * = Required

Gender: *	Male Female
First Name: *
Last Name: *		Former Last Name: [if changed]
Date of Birth: * (eg. 05/21/1970)
E-Mail Address:		Former E-Mail Address: [if changed]

Your Membership #

Membership #:	if known [bottom right corner of any Lifesaving Society wallet card]
Membership2 #:	If you have 2 membership numbers put the second one here

Your Current Address

Street Address: *		Former Street Address: [if changed]
Sub Address:		Former Sub Address: [if changed]
City: *		Former City: [if changed]
Prov/Ter: *		Former Prov/Ter: [if changed]
Country: *		Former Country: [if changed]
Postal Code: *		Former Postal Code: [if changed]

Your Current Contact Information

Telephone #: *		Former Telephone #: [if changed]
Fax #:		Former Fax #: [if changed]

All information collected and transmitted by this form is subject to the Lifesaving Society BC & Yukon Branch PRIVACY STATEMENT.

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