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 OrganizationWebsite Upload New Organization Logo Drop files here or Accepted file types: jpg, gif, png. 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?YesNoWhat level obstetric services do you provide?Level ILevel IILevel IIILevel IVWe do not provide obstetric services.What level neonatal services do you provide?Level ILevel IILevel IIILevel IVWe do not provide neonatal services.Representative Contact InformationContact information for the designated lead representative:NameEmail PhoneAlternate Contact InformationContact information for possible alternate(s) who may be representing your organization instead of the designated representative. NameEmail PhoneDo you have another alternate name to add?*YesNoSecond Alternate NameEmail PhoneDo you have another alternate name to add?*YesNoThird Alternate NameEmail PhoneDo you have another alternate name to add?*YesNoFourth Alternate NameEmail 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.Typed Name of Signer*Date* Date Format: MM slash DD slash YYYY
