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SOUTHERN REGION BLACK LAW STUDENTS ASSOCIATION 42ND Annual Convention Voting Rights Assignment This form is for the assignment of voting rights to a qualified proxy on behalf of a chapter. If a chapter is not sending its official voting representative to plenary, then the voting rights of that chapter may be assigned to another authorized representative attending plenary in person. That person must be a financially active member of SRBLSA and certified by the SRBLSA Regional Director of Membership. To help facilitate the processing and verification process, this form along with the Certification for Recognized Proxy Holder form should be sent to the Director of Membership at srblsa.membership@nblsa.org by January 30, 2013. After this date, forms should be submitted in person. Anyone bringing these forms to the Convention must submit them to the Regional Director of Membership at least ten minutes before the plenary session for which the proxy is required. This page is to be completed by the chapter president if the chapter will not be present for plenary CHAPTER ___________________________________________________________________________ CHAPTER’S NBLSA EMAIL ADDRESS ___________________________________________________ CHAPTER PRESIDENT ________________________________________________________________ CHAPTER PRESIDENT’S EMAIL ADDRESS _______________________________________________ CHAPTER PRESIDENT’S PHONE NUMBER _______________________________________________ Plenary Session(s) for which proxy is needed: Session 1
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Session 2
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Session 3
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Session 4
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For the 2013 Annual Convention of the Southern Region of the National Black Law Students Association, I hereby designate the following representative as the OFFICIAL VOTING PROXY for _______________ Chapter. NAME OF PROXY HOLDER: ____________________________________________________________ PROXY HOLDER’S EMAIL ADDRESS: ____________________________________________________ PROXY HOLDER’S PHONE NUMBER: ____________________________________________________ PROXY HOLDER’S CHAPTER: __________________________________________________________
I hereby certify that I am the duly elected President/authorized representative of the _____________________chapter: _____________________________________
SIGNATURE OF CHAPTER PRESIDENT PLEASE SUBMIT TO SRBLSA.MEMBERSHIP@NBLSA.ORG BY JANUARY 30, 2013. -------------------------------------------------------------------------------------------------------------------------------------------For use by Director of Membership only: Rcvd Date: __________ Rcvd by: __________ Number of Votes: __________ Verified: __________
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SOUTHERN REGION OF THE NATIONAL BLACK LAW STUDENTS ASSOCIATION 42ND Annual Convention Voting Rights Assignment
CERTIFICATION FOR RECOGNIZED PROXY HOLDER To help facilitate the processing and verification process, this form should be sent to the Regional Director of Membership at srblsa.membership@nblsa.org by January 30, 2013. After this date, forms should be submitted in person. Anyone bringing these forms to the Convention must submit them to the Regional Director of Membership at least one hour before the plenary session for which the proxy is required. This page is to be filled in by the RECOGNIZED PROXY HOLDER. The Proxy Holder should email this form to srblsa.membership@nblsa.org by January 30, 2013 AND bring a copy to plenary. CHAPTER ASSIGNING THE PROXY: _____________________________________________________ NAME OF PROXY HOLDER: ____________________________________________________________ PROXY HOLDER’S EMAIL ADDRESS: ____________________________________________________ PROXY HOLDER’S PHONE NUMBER: ____________________________________________________
I hereby certify that: I am a member in good standing of the _______________ chapter. I have been duly appointed as a PROXY HOLDER for the above named chapter. I understand that it may be revoked at any time by the assigning chapter. _____________________________________
SIGNATURE OF PROXY HOLDER PLEASE SUBMIT TO SRBLSA.MEMBERSHIP@NBLSA.ORG BY JANUARY 30, 2013.
-------------------------------------------------------------------------------------------------------------------------------------------For use by Director of Membership only: Rcvd Date: __________ Rcvd by: __________ Number of Votes: __________ Verified: __________