Request for CMG stakeholder status

Submit this form to register an X12 member or non-member's interest in being recognized as a stakeholder of a CMG with a commitment to active participation. For more information, see External Code List (CAP12). For X12 members, the form must be completed by the X12 member's primary representative.

Fields Marked with a * are required
*Primary Representative's or Non-member representative's name
*Email of the person entered above
Member Name (if applicable)
*CMG the request is for
*A description of the member's or non-member's material interest in the specific CMG's activities
*Name of the individual who has met the attendance requirement and will serve as the CMG constituent
*Email of the person entered above
*Dates of the qualifying meeting attendance
Name of the individual who shall be recognized as the CMG alternate
Email of the person entered above