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2021 Virtual AGM Group Voting Authorization Form
Deadline: March 1st at 5pm EST:
Which Region are you submitting this form for?
*
Southern
Midwest
Western
Mid-Atlantic
Northeast
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
CAPTCHA
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