Please be sure to contact your State and Chapter Secretaries and provide them with your new address as well.
To submit a registration electronically using this form:
(1) Follow the instructions to enter the requested information
(2) When form is complete click "Register" at the bottom of the form.

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Type the information requested into the white areas below. Use the "tab" key to get to next block.
 
National Number: State Society:

Name:

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Old Address:

Old City:Old State:Old Zip:
             
Old E-mail:

Old Phone:

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New Address:

New City:New State:New Zip:
               
New E-mail:

New Phone:



Submission Date:

Submitter (if not Member):

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Submitting the Form

Note:  You may print a copy of the completed form for your records by going to [File] [Print] on your computer BEFORE you submit the form.

Note:  To submit this form by mail, mail to:

NSSAR Staff Registrar
1000 S. 4th Street
Louisville KY 40203

Now you may click on either
the "Submit" button below to submit the data to the Registrar
or the "Clear Form" to start over again.

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Submitting the Form