The Honor Society of Phi Kappa Phi

 

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Convention Delegate Nomination Form

DELEGATE INFORMATION

This is to certify that the following delegate has been elected to represent this chapter as an official delegate to the 2012 Biennial Convention in St. Louis, Missouri from August 9-11, 2012. She or he is authorized to cast this chapter's vote on all matters considered at the Convention.
Chapter Delegate Name  

First
Last
Address  

Street Address

Address Line 2

City
State

Zip Code
Country
Phone  

123 		-
456 		-
7890
Email  
e.g., name@university.edu
Member Number  
Position  
e.g., Past President, Secretary, etc.
Active Member at Chapter #  
e.g., 043
Chapter at  
College or University

NON-DELEGATE INFORMATION

In addition to the delegate named above, this chapter will have the following additional chapter members in attendance as non-delegates:
Non-Delegate Name  

First
Last
Address  

Street Address

Address Line 2

City
State

Zip Code
Country
Phone  

123 		-
456 		-
7890
Email  
e.g., name@university.edu
---------------------------------------------
Non-Delegate Name  

First
Last
Address  

Street Address

Address Line 2

City
State

Zip Code
Country
Phone  

123 		-
456 		-
7890
Email  
e.g., name@university.edu

CHAPTER PRESIDENT AUTHORIZATION

Chapter President Name  

First
Last
Work Phone  

123 		-
456 		-
7890
Home Phone  

123 		-
456 		-
7890
Email  
e.g., name@university.edu
Chapter President Member Number  
Virtual Signature

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