Membership Information Update Membership Information Change Form Use this form for any changes to your enrollment form. You only have to complete fields for which there are changes. You will receive a copy of the document after you submit it. Official Name of Organization*Name as it appears in WisPQC materials. New Name of Organization Website Upload New Organization Logo Drop files here or Select files Accepted file types: jpg, gif, png, Max. file size: 32 MB. New Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is your organization a hospital that has changed its obstetric or neonatal level of care through participation in WAPC's Self-Assessment Survey process? Yes No What level obstetric services do you provide? Level I Level II Level III Level IV We do not provide obstetric services. What level neonatal services do you provide? Level I Level II Level III Level IV We do not provide neonatal services. Representative Contact InformationContact information for the designated lead representative:Name Email PhoneAlternate Contact InformationContact information for possible alternate(s) who may be representing your organization instead of the designated representative. Name Email PhoneDo you have another alternate name to add?* Yes No Second Alternate Name Email PhoneDo you have another alternate name to add?* Yes No Third Alternate Name Email PhoneDo you have another alternate name to add?* Yes No Fourth Alternate Name Email PhoneElectronic SignatureIf available, the electronic signature of individual with authority to act on behalf the organization. *Files must be no larger than 2MB.Accepted file types: jpg, gif, png, Max. file size: 32 MB.Typed Name of Signer* Date* MM slash DD slash YYYY
