Business Liaison Transfer

Under the terms of ACA Business Affiliation, individual benefits are transferable ONLY to the business's liaison (Individual membership) of the Business Affiliation. The business can transfer the balance of this Liaison (individual) membership to another named person by completing the form below:

Business

Company Name:

ACA Business Affiliate ID #:

Former ACA Liaison Information

We must have a forwarding address for the former liaison, otherwise mailings will continue to their former address.

Former ACA Liaison Name:

ACA Member ID #:

Forwarding Address:

City:

State:

Zip:

This address is my:

Home

Work

Phone:

E-mail:

Will this individual remain with the business listed above?:

Yes

If so, please indicate if their ACA membership should continue:

Yes

If ACA Membership is to continue, we will send a renewal invoice. If membership is not to continue, former liaison's membership will lapse immediately.

New ACA Liaison Information

Name:

ACA Individual Member ID #:

This address is my:

Home

Work

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail: *

Public Contact Information

Name:

Phone:

Fax:

E-mail:

Web site:

Form Completed By

Name: *

Phone: *

E-mail: