Request for X12M stakeholder status

Completed by: An X12 member's primary representative

Fields Marked with a * are required
*Member Name
*Primary Representative Name
*Primary Representative Email
*A description of the member's material interest in the X12M activities
*Name of the member representative who has met the attendance requirement as an observer and will serve as the member's X12M constituent
*Email of the person entered above
*Dates of the qualifying meeting attendance