District 4 District Position Change Form

Please use this form to submit changes to trusted servants serving in a district position, such as a district officer, a district standing committee chair, a District Committee Member, or an Alternate District Committee Member. These changes will be entered in the South Florida Area 15 registrar database as well as in Fellowship Connection, the General Service Office’s database, to ensure these trusted servants stay connected to your district, to South Florida Area 15, and to the General Service Office.

Submitting this form will send the information to both the District 4 and Area 15 Registrars.

All fields must be completed for your district registrar to process this form for your group.

>>>What information do you want to update? Please only fill out what is changing: <<<

>>> District Chairperson

• District Chairperson

Name of outgoing district chairperson

Name of incoming district chairperson

New chairperson's address (street, city, state, ZIP code)

New chairperson's telephone number

New chairperson's Email Address

New chairperson's start date

>>> Alternate district chairperson

• Alternate district chairperson

Name of outgoing alternate district chairperson

Name of incoming alternate district chairperson

New alternate chairperson's address (street, city, state, ZIP code) (copy)

New alternate chairperson's telephone number

New alternate chairperson's Email Address

New alternate chairperson's start date

>>> District treasurer

• District treasurer

Outgoing district treasurer name

Incoming district treasurer name

New treasurer street address (street, city, state, ZIP code)

New treasurer telephone number

New treasurer Email Address

New treasurer start date

>>> Alternate district treasurer

• Alternate district treasurer

Outgoing alternate district treasurer name

Incoming alternate district treasurer name

New alternate treasurer street address (street, city, state, ZIP code)

New alternate treasurer telephone number

New alternate treasurer Email Address

New alternate treasurer start date

>>> District registrar

• District registrar

Outgoing district registrar name

Incoming district registrar name

New registrar street address (street, city, state, ZIP code)

New registrar telephone number

New registrar Email Address

New registrar start date

>>> Alternate district registrar

• Alternate district registrar

Outgoing alternate district registrar name

Incoming alternate district registrar name

New alternate registrar street address (street, city, state, ZIP code)

New alternate registrar telephone number

New alternate registrar Email Address

New alternate registrar start date

>>> District secretary

• District secretary

Outgoing district secretary name

Incoming district secretary name

New secretary street address (street, city, state, ZIP code)

New secretary telephone number

New secretary Email Address

New secretary start date

>>> Alternate district secretary

• Alternate district secretary

Outgoing alternate district secretary name

Incoming alternate district secretary name

New alternate secretary street address (street, city, state, ZIP code)

New alternate secretary telephone number

New alternate secretary Email Address

New alternate secretary start date

>>> District Committee Member

• District Committee Member

Outgoing DCM name

Incoming DCM name

DCM Sub district

New DCM street address (street, city, state, ZIP code)

New DCM telephone number

New DCM Email Address

New DCM start date

>>> Alternate District Committee Member

• Alternate District Committee Member

Outgoing alternate DCM name

Incoming alternate DCM name

ADCM Sub district

New alternate DCM street address (street, city, state, ZIP code)

New alternate DCM telephone number

New alternate DCM Email Address

New alternate DCM start date

>>> District standing committee chair

• District standing committee chair

Outgoing district standing committee chair

New district standing committee chair

Name of standing committee

New standing committee chair street address (street, city, state, ZIP code)

New standing committee chair telephone number

New standing committee chair Email Address

New standing committee chair start date

If available, does incoming standing committee chair want to receive a committee kit from GSO?

• Yes
• No

>>> Other district position

• Other district position

Outgoing trusted servant

Position

Name of incoming trusted servant

New trusted servant’s street address (street, city, state, ZIP code)

New trusted servant’s telephone number

New trusted servant’s Email Address

New trusted servant’s start date

>>> Submitted by: Name *

>>> Submitted by: Email *

>>> Submitted Date: *

>>> Submitted by Telephone Number: *

In case the Registrar has any questions. Thank You!

Submit to District 4 Registrar