Detachment Delegate Form. Only To be Completed By Your Detachment.

Registrant Name

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Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

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Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

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Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

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Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

Registrant Name

Please check ALL the appropriate boxes

Registrant is Attending Registrant is Not Attending Registrant is A Delegate Registrant is an Alternate Registrant is a Guest Registrant's First Time?

How many over all attending?*

1 - $5.00 2 - $10.00 3 - $15.00 4 - $20.00 5 - $25.00 6 - $30.00 7 - $35.00 8 - $40.00 9 - $45.00 10 - $50.00 11 - $55.00 12 - $60.00 13 - $65.00 14 - $70.00 15 - $75.00

Attestation:*

I certify that the following members listed on this delegate form are paid members of my Detachment and will represent this Detachment at the Department Convention 2024. I further certify that these members are in good standing with the Department. I understand that members not in good standing can not be registered.

Attestation Signature:*

My Detachment is in good standing with Department.*

Yes No