EmailMeForm
Change in demographics
Complete and submit this form in order to change your information on the members registry. Update only the new information
Name
*
First
Last
Change Name to:
First
Last
Change Email to:
IBCLC Number if Applicable
Change Personal Address to:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Change Business Address to:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
