Change Contact Information

Change your contact information

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Take a few minutes to complete the form below. Once completed, make sure that you submit the form by pressing the submission button at the bottom of this page. An email confirmation will be sent to you within 5 working days. Thank you in advance for your time!

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{{#input:type=hidden|name=formmailer|value=formmailer}}	{{#input:type=hidden|name=title|value=Updating contact information thank you}}
First Name:	{{#input:type=text|name=First name }}
Last Name:	{{#input:type=text|name=Last name}}
Institute / Organization:	{{#input:type=text|name=Institute|size=40}}
Department:	{{#input:type=text|name=Department|size=40}}
Postal address 1:	{{#input:type=text|name=Postal address 1|size=40}}
Postal address 2:	{{#input:type=text|name=Postal address 2|size=40}}
Town/City:	{{#input:type=text|name=Town/City}}
Postal code:	{{#input:type=text|name=Postal code|size=15}}
State:	{{#input:name=State|type=select|value=| State: NO STATE Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming }}
Country:	{{#input:type=text|name=Country}}
Email address:	{{#input:type=text|name=Email address}}
Phone:	{{#input:type=text|name=Phone|size=15}}
Fax:	{{#input:type=text|name=Fax|size=15}}
Member of workgroup:	{{#input:type=checkbox|name=terrestrial}} Terrestrial
More than one option possible	{{#input:type=checkbox|name=Coastal}} Coastal
	{{#input:type=checkbox|name=Marine}} Marine
	{{#input:type=checkbox|name=EKT}} Education & Knowledge Transfer
	{{#input:type=checkbox|name=Cyberinformatics}} Cyberinformatics
And / or member of a Focus Research Group:	{{#input:type=checkbox|name=Hydrology}} Hydrology Focus research group
More than one option possible	{{#input:type=checkbox|name=Carbonate}} Carbonate Focus research group
	{{#input:type=checkbox|name=Chesapeake}} Chesapeake Focus research group
	{{#input:type=submit|value=Submit form}}