2021 TBS Chapter Delegate & Proxy Request

Forms submitted to National Headquarters on or before June 1, 2021, will receive primary consideration for committee seating. Don’t forget - you must have a current membership card to be seated as a delegate.

Note: As you progress through this form, you may have to scroll back to the top when changing pages within the form.

Important Reminders
1. Each delegate or alternate delegate must have a valid membership card.
2. The National President may create more committees for the convention should the need be apparent.
3. This form fulfills the National Constitution provision requiring a signed official statement verifying selection as a delegate or alternate delegate.

Send a written notice to the National Headquarters (by mail, by e-mail to [email protected], or by fax to 405.372.2363) should the name, address, phone numbers or e-mail address of the delegate or alternate delegate change.

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Person submitting this form Person submitting this form First Middle Last
Email
Chapter Information
Chapter Name
Organization
District
School Name
Will your chapter be sending a delegate to the 2021 National Convention?

Will your chapter be sending a delegate to the 2021 National Convention? Yes No
Chapter President's Name Chapter President's Name First Middle Last
Chapter President's Email
Chapter Sponsor's Name Chapter Sponsor's Name Title First Last Suffix
Sponsor's Email
Delegate Information
Official Delegate Official Delegate First Middle Last
Official Delegate's Summer Address Official Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Official Delegate's Email
Official Delegate's Cell Phone Official Delegate's Cell Phone - ### - ### ####
1st Alternate Delegate 1st Alternate Delegate First Middle Last
1st Alternate Delegate's Summer Address 1st Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
1st Alternate Delegate's Email
1st Alternate Delegate's Cell Phone 1st Alternate Delegate's Cell Phone - ### - ### ####
2nd Alternate Delegate 2nd Alternate Delegate First Middle Last
2nd Alternate Delegate's Summer Address 2nd Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
2nd Alternate Delegate's Email
2nd Alternate Delegate's Cell Phone 2nd Alternate Delegate's Cell Phone - ### - ### ####
3rd Alternate Delegate 3rd Alternate Delegate First Middle Last
3rd Alternate Delegate's Summer Address 3rd Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3rd Alternate Delegate's Email
3rd Alternate Delegate's Cell Phone 3rd Alternate Delegate's Cell Phone - ### - ### ####
4th Alternate Delegate 4th Alternate Delegate First Middle Last
4th Alternate Delegate's Summer Address 4th Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
4th Alternate Delegate's Email
4th Alternate Delegate's Cell Phone 4th Alternate Delegate's Cell Phone - ### - ### ####
5th Alternate Delegate 5th Alternate Delegate First Middle Last
5th Alternate Delegate's Summer Address 5th Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
5th Alternate Delegate's Email
5th Alternate Delegate's Cell Phone 5th Alternate Delegate's Cell Phone - ### - ### ####
6th Alternate Delegate 6th Alternate Delegate First Middle Last
6th Alternate Delegate's Summer Address 6th Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
6th Alternate Delegate's Email
6th Alternate Delegate's Cell Phone 6th Alternate Delegate's Cell Phone - ### - ### ####
7th Alternate Delegate 7th Alternate Delegate First Middle Last
7th Alternate Delegate's Summer Address 7th Alternate Delegate's Summer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
7th Alternate Delegate's Email
7h Alternate Delegate's Cell Phone 7h Alternate Delegate's Cell Phone - ### - ### ####
Committee Preference

Rank the following committees in order of preference. 1 for most preferred, and 5 for least preferred.
	1	2	3	4	5
Nominations	Nominations1	Nominations2	Nominations3	Nominations4	Nominations5
Colonization & Membership	Colonization & Membership1	Colonization & Membership2	Colonization & Membership3	Colonization & Membership4	Colonization & Membership5
History & Traditions / Ritual & Regalia	History & Traditions / Ritual & Regalia1	History & Traditions / Ritual & Regalia2	History & Traditions / Ritual & Regalia3	History & Traditions / Ritual & Regalia4	History & Traditions / Ritual & Regalia5
Jurisdiction	Jurisdiction1	Jurisdiction2	Jurisdiction3	Jurisdiction4	Jurisdiction5
Programs	Programs1	Programs2	Programs3	Programs4	Programs5

2021 TBS Chapter Delegate & Proxy Request

2021 TBS Chapter Delegate & Proxy Request

Chapter Information

Delegate Information

Committee Preference