Director Change FormSuzanne Wallace2023-03-01T22:50:40-08:00

JPIA Director Change Form

Change of Director fields marked with * are required fields. As an alternative, you may also download this form, type in the information into the form fields, save the file as an adobe document formatted file, and either fax it to (916) 774-7040 or email it to Chimene Camacho.

JPIA DIRECTOR

Please select your district from the drop down menu below: *

Name of JPIA Director (Must be a member of the agency's board of directors.) *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Assuming Office Date (Assuming the position of JPIA Director) *

Email

Change of Director fields marked with * are required fields. As an alternative, you may also download this form, type in the information into the form fields, save the file as an adobe document formatted file, and either fax it to (916) 774-7040 or email it to Chimene Camacho.

JPIA DIRECTOR

Please select your district from the drop down menu below: *

Name of JPIA Director (Must be a member of the agency's board of directors.) *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Assuming Office Date (Assuming the position of JPIA Director) *

Phone