EmailMe Form - Affiliate Voter Certification Form

Affiliate Certification Form

This is to certify that the following affiliate chapter met on the date listed below for its annual meeting and the following person, who is a regular member of the Association, was designated to cast the Affiliate
vote(s) on Tuesday, July 17, 2012 at the 87th Annual Meeting of the Association in Las Vegas, NV.

Affiliate Name *

Date of Meeting *

MM / DD / YYYY

Person Designated to Cast Vote on Affiliate's Behalf *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Office Number *

### - ### - ####

Home Number *

### - ### - ####

Date of Election *

MM / DD / YYYY

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