For the state of:

Please fill out the information below to submit the names of your officials to the AARC. This should be done as soon as you know the names of your officers for the coming year.

We will pull the address and email they have indicated is their “Primary” on their AARC member record. (Member numbers, as requested below, are very helpful so that we can ensure we get the correct individual noted in our records. However, the number is not mandatory.)  Ending date of term is very important for our record-keeping.

Contact Information

Officers and Committees
President:
Member Number:
Term ends:
   
President-elect:
Member Number:
Term ends:
   
Past President:
Member Number:
Term ends:
   
Vice President:
Member Number:
Term ends:
   
Secretary:
Member Number:
Term ends:
   
Treasurer:
Member Number:
Term ends:
   
Delegate:
Member Number:
Term ends:
   
Delegate:
Member Number:
Term ends:
   
Delegate:
Member Number:
Term ends:
   
Membership Committee Chair:
Member Number:
Term ends:
   
PACT Representative:
Member Number:
Term ends:
   
PACT Representative:
Member Number:
Term ends:
   
Medical Advisor:
Member Number:
Term ends:
   

Executive Office
Do you have an executive office? Yes       No
Contact Person:
Address:
 
City:
State:
Zip:
Email:
Phone:
   

Revenue Sharing
We send the Quarterly Revenue Sharing check to the State Society President. If you wish to have a different individual receive that check, please provide their contact information—
Name:
Address:
 
City:
State:
Zip:
Email:
Phone:
   

Monthly Member List
We send the Monthly Membership List to the State Society President. If you wish to have a different individual receive that list, please provide their contact information—
Name:
Address:
 
City:
State:
Zip:
Email:
Phone:

I, attest that I am the duly-elected President or Past President of the [State] Society and that I have the authority to submit this form with the names of our officers and committee members.

My email address is:

Your name and email address are required to submit this form.