2021 Virtual AGM Group Voting Authorization Form

Deadline: March 1st at 5pm EST:

Which Region are you submitting this form for?*

What type of Group are you submitting this form for?*

Student Group
Local Group

What is the name and number of your Group? (School Groups do not have a number)*

City:*

State:*

Group Coordinator/Chair Name:*

First Last

As the Group Coordinator/Chair, you are responsible for completing this form.

Group Coordinator/Chair Phone Number:*

Group Coordinator/Chair Email:*

Group Delegate Name:*

First Last

Please provide the name of the person who will be responsible for the group voting card. This does not necessarily have to be the Group Coordinator/Chair.

Group Delegate Phone Number:*

Group Delegate Email:*

Back-up to Group Delegate Name:

First Last

Should the Group Delegate be unable to pick-up the Group voting card, this person will also be permitted to pick-up the card on behalf of the Group.

Back-up to Group Delegate Phone Number:

2nd Back-up to Group Delegate Name:

First Last

Should the Group Delegate and the Back-up to the Group Delegate be unable to pick-up the Group voting card, this person will also be permitted to pick-up the card on behalf of the Group.

2nd Back-up to Group Delegate Phone Number:

Has the Group discussed the resolutions?*

All
Some
None

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2021 Virtual AGM Group Voting Authorization Form

Deadline: March 1st at 5pm EST:

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