Action Center / Submit New Contact Information / Association of Indiana Counties

Submit New Contact Information

You are here: Home •Action Center•Submit New Contact Information

Action Center Home | Login

Step 1 of 1

The AIC strives to keep its records as up to date as possible. Please provide any new or updated contact information.

* Denotes a required field

Please fill out form as completely as possible.

First Name*

Last Name*

Title*

County or Organization Name*

Political party affiliation if elected

Term of office end date if elected

Name of person you are replacing if appointed to fill a term of an

elected official

Address Line One*

Address Line Two

City*

Please Do Not Complete The Following Field

State*

ZIP Code*

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Fax

Phone Area Code-Phone 3-Phone 4 ext Extension

Email*

Verification*

The following x errors were detected in the information you entered.

Please correct these errors and try again.

There is an error in the information you entered.

Please try again.