Chapter Delegation Form
Please remember to update this document if any of the below information changes. The information submitted through this form will not be sold or distributed outside the NPHC of Chicago, Inc.
Date
*
-
Month
-
Day
Year
Date
Email Address of person completing this form.
*
example@example.com
*
Organization
Chapter Name
Chapter's Mailing Address
*
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Chapter President Information
*
President's Name
President's Email
Chapter President Phone Number
Please enter a valid phone number.
President's Current Term
*
1st Term
2nd Term
Chapter's Email Address Chapter's Website
*
Chapter's Email Address
Chapter's Website
Chapter Fiscal Year
*
January -December
July - June
Other
Chapter Size - Number of Financial Members
Date Dues Paid
*
-
Month
-
Day
Year
Date
Chapter Treasurer Information
*
First Name
Last Name
Please select if this form is a New Delegate Request or an update to Delegates?
*
Please Select
New
Update
If this request is replacement of a Delegate(s), please provide full name and email address of Delegate being replace. This is needed so that we can remove them from the Google Group.
*
Name
Email
If this request is replacement of a Delegate(s), please provide full name and email address of Delegate being replace. This is needed so that we can remove them from the Google Group.
*
Name
Email
Primary/Voting Delegate Information
*
Name
Email Address
Phone Number
Email Address
Zip Code
Add to Listserve
*
Yes
No
Committee Member of (check all that apply):
*
By-laws
Community Outreach
Ecumenical Service
Greek Picnic
Membership
Networking Social
Technology/Website
Public Relations
Sankofa
Scholarship
Social Action
Undergrad Liaison
Corporate Sponsorship
5K Marathon
Auditing
Budget/Finance
Fundraising
Alternate Delegate Information
Name
Email Address
Phone Number
Email Address
Zip Code
Add to Listserve
Yes
No
Committee Member of (check all that apply):
By-laws
Community Outreach
Ecumenical Service
Greek Picnic
Membership
Networking Social
Technology/Website
Public Relations
Sankofa
Scholarship
Social Action
Undergrate Liaison
Corporate Sponsorship
5K Marathon
Auditing
Budget/Finance
Fundraising
Alternate Delegate Information
Name
Email Address
Phone Number
Email Address
Zip Code
Add to Listserve
Yes
No
Committee Member of (check all that apply):
By-laws
Community Outreach
Ecumenical Service
Greek Picnic
Membership
Networking Social
Technology/Website
Public Relations
Sankofa
Scholarship
Social Action
Undergrate Liaison
Corporate Sponsorship
5K Marathon
Auditing
Budget/Finance
Fundraising
Print
Submit
Should be Empty: