Triennial Delegate Certification | National Episcopal Church Women

As soon as you have chosen your delegates, please fill out and return the Certification Forms from your Delegate Packet, or submit the form below directly to the Triennial Meeting Registrar. They must be returned no later than December 15, 2011.

TRIENNIAL DELEGATE CERTIFICATION FORM

Deadline for submission is December 15th, 2011. Each DIOCESE may certify no more than 4 delegates. Each ORGANIZATION may certify no more than 2 delegates.

Diocese or Organization?*
- Diocese
- Organization
Full Name of Diocese or Organization*
Province*
HEAD OF DELEGATION
Name*
Title
Address (Street)*
City, State & Zip*
Email*
Please enter a valid email address to receive confirmation that your delegation credentials have been submitted.
Phone*
DELEGATE 1
Name*
Title
Address (Street)*
City, State & Zip*
Email
Phone*
DELEGATE 2
Name*
Title
Address (Street)*
City, State & Zip*
Email
Phone*
DELEGATE 3
Name*
Title
Address (Street)*
City, State & Zip*
Email
Phone*
ALTERNATE 1
Name*
Title
Address (Street)*
City, State & Zip*
Email
Phone*
ALTERNATE 2
Name*
Title
Address (Street)*
City, State & Zip*
Email
Phone*
Additional Information:
Please use this space to provide complete information for additional alternates, should you have more than 2.

TRIENNIAL DELEGATE CERTIFICATION FORM

HEAD OF DELEGATION

DELEGATE 1

DELEGATE 2

DELEGATE 3

ALTERNATE 1

ALTERNATE 2