Request to add an X12M constituent

Completed by: An X12 member's primary rep or the current X12M constituent for the member

Fields Marked with a * are required
*Member Name
*Primary Representative's name or Current X12M constituent's name
*Email of the person entered above
Name of the member representative who has met the attendance requirement as an observer and will replace the currently named X12M representative as the stakeholder's X12M alternate 
Email of the person entered above
Dates of the qualifying meetings
Effective date for the change