Contact Update Form

JPA(Required)

Agency(Required)

Agency Adress(Required)

Street Address Address Line 2 City ZIP Code

Please choose one of the following:(Required)

Adding a New Contact

Changing a Current Contact

Would this contact like to receive ERMA Training Bulletins?(Required)

Yes

No

Current Contact Information

Please use this section to substitute a training or EPL contact within your organization. You need to provide the details of the existing staff member and the details of the new staff member you wish to add.

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Type of contact (select all that apply)(Required)

Employee Protection Line (EPL)

Human Resources Contact

Training Contact

I don't know

New Contact Information