Name: (required)     

Club: (required)       

District:  (required)   

Position Held in District and/or State:   

Newsletter Subscriber: YES or NO     

New Info:  [Please fill out only changed data.]

Street:   

City:      

Zip:       

New Email:   

New Phone: 

     Please check your data for accuracy before submitting.  Thanks!

Security Code:   

         Submitting this form sends the info to the GFWC VA Executive Secretary.