MAINTAIN CONTACT DETAILS

Use this form to notify the HLA of personnel changes.

We like to maintain the contact details of 2 people from each hospice. Subscription renewal notices will be sent to the primary contact. Please supply an alternative email address for subscription renewals if required.

Hospice / Lottery name*

Primary Contact

Name

First

Last

Position

E-mail

Phone:*

Area Code

Phone Number

New Member Area login required?

Yes

Is this a replacement for someone who has left?

Yes

Who has left?

First

Last

Secondary Contact

Name 2

First

Last

Position 2

E-mail 2

Phone 2:

Area Code

Phone Number

New Member Area login required ?

Yes

Is this a replacement for someone who has left ?

Yes

Who has left ?

First

Last

E-mail for subscription renewals:

Use this area to notify us of other changes:

Show us you are human: