2026 WPC Delegate|Proxy Designation

Kappa Alpha Psi Fraternity, Inc.
Western Province Council
DELEGATE AND PROXY FORM INSTRUCTIONS

PURPOSE OF FORMS

The Delegates Form is used to register your chapter’s delegates. Chapters should also include the names of the alternate delegates on this form; the alternates will represent your chapter if your delegates cannot.

The Proxy Form is used only if no members of your chapter attend the Province Council. It serves to transfer your chapter’s votes to the Brother of your choosing. Thus, the Proxy Form should NOT contain the name of anyone from your chapter.

INSTRUCTIONS

General:

1. No brother can arrive and declare himself a delegate; that authority must come from the chapter. Therefore, if a brother discovers that he is the only member of a chapter registered, he cannot request the votes unless he (a) is/has been sanctioned as a delegate or alternate by the chapter, and (b) has his credentials validated.

2. Your chapter will not vote unless you EITHER (a) register your delegates and alternates using the Delegate Form (any eligible member from your chapter can be an alternate), OR (b) register a proxy using the Proxy Form.

3. Be certain that all of your questions are answered before filling out these documents; it could save your chapter $25.00 which will be assessed by the Province Polemarch for failure to comply.

Chapter Delegate Form:

1. One chapter delegate can carry all three (3) votes, two chapter delegates can carry one & one-half (1.5) votes each, or three (3) chapter delegates can carry one vote each.

2. You can list up to three (3) alternates. We cannot make the decision regarding who can vote for your chapter, but we can determine who is eligible.

3. A delegate cannot be an alternate.

4. Choose delegates or alternates who will represent your chapter for the entire convention. Once votes have been picked up, delegates will not be allowed to make changes to their status or number of votes.

5. The Chapter Polemarch and Chapter Keeper of Records will be sent a signature request via email, based on the emails provided.

Proxy Form:

1. No member can vote the proxy of more than one (1) chapter.

2. Do not list anyone who is a member of your chapter on the Proxy Form.

Create Date*

MonthDayYear
Todays's Date
Hour MinutesAM/PM Option
Delegation Registration Form
Submitter Information

Member submitting form
Submission Type*

NewUpdate Existing Delegate/Proxy Form
Submitter Name:*

First NameLast Name
Submitter Email Address*
nupe@kapsi-western.org
Submitter Kappa Initiation Membership Number*
Fraternity’s unique, system-assigned identifier
Registering Chapter*
Registration Type*

DelegateProxy
Submitter Phone Number*
Please enter a valid phone number.
Chapter Type*

AlumniUndergraduate

Chapter Officers

Polemarch, Vice Polemarch, Keeper of Records, and Chapter Advisor
Chapter Polemarch Name:*

First NameLast Name
Chapter Polemarch Email:*
nupe@kapsi-western.org
Chapter Vice Polemarch Name:*

First NameLast Name
Vice Polemarch Email:*
nupe@kapsi-western.org
Chapter KOR Name:*

First NameLast Name
Chapter KOR Email:*
nupe@kapsi-western.org
Chapter Advisor Name (Undergaduate Only):

First NameLast Name
Chapter Advisor Email:*
nupe@kapsi-western.org

Delegate | Alternate Appointment
Delegates

Enter chapter delegates (must be a brother in your chapter)
Delegate1 Name:

First NameLast Name
Delegate 1 ID
Kappa Member ID
Delegate 1 Email:
Where ballots will be mailed
Delegate 2 Name:

First NameLast Name
Delegate 2 ID
Kappa Member ID
Delegate 2 Email:
Where ballots will be mailed
Delegate 3 Name:

First NameLast Name
Delegate 3 ID
Kappa Member ID
Delegate 3 Email:
Where ballots will be mailed
Alternates

Enter alternate chapter delegates (must be a brother in your chapter)
Alternate 1 Name:

First NameLast Name
Alternate 1 ID
Kappa Member ID
Alternate 1 Email:
Where ballots will be mailed
Alternate 2 Name:

First NameLast Name
Alternate 2 ID
Kappa Member ID
Alternate 2 Email:
Where ballots will be mailed
Alternate 3 Name:

First NameLast Name
Alternate 3 ID
Kappa Member ID
Alternate 3 Email:
Where ballots will be mailed

PROXY FORM

Do NOT list anyone from your chapter on this section of form!
INSTRUCTIONS:
- Print or type all information.
- The necessary fees required to register one delegate for your chapter must be submitted in addition to this form. (Payment may be submitted via the Province website; the registration deadline & fee schedule still applies.)
- Do not list anyone from your chapter on this form. If you input the name of someone from your chapter on this form, you are filling out this form incorrectly. See “purpose of forms” section on the instructions page.
- IF YOUR CHAPTER LATER CHOOSES TO SEND A CERTIFIED DELEGATE, THIS FORM IS NO LONGER VALID ONCE HE ARRIVES. (This form is valid only if your chapter does not send a certified delegate).
Proxy Vote Information

Enter proxy vote information below.
This is to certify that the Brother listed below is duly authorized to cast three (3) votes on behalf of the Chapter listed below on any matter properly brought before the 79th Western Province Council (2026):
Proxy Voter Name:

First NameLast Name
Proxy Voter Email:
Where ballots will be mailed
Proxying Chapter

Approvals
We certify that the brothers reported as Delegates are in good standing with their local Chapter, the Province and with the Grand Chapter. We further certify that they will be properly registered for attendance at the #79th Western Province Council.

Certification will be verified by Western Province Keeper of Records Office. Any changes in certification are to be communicated to the Western Province Keeper of Records Office, in writing, and signed by the chapter officers submitting this certificate.
Approving Chapter Polemarch

First NameLast Name
Approving Chapter Polemarch Signature:
Approving Chapter Polemarch Email:
example@example.com
Approving ATTEST - Chapter KoR:

First NameLast Name
Approving Chapter KoR Signature:*
Approving Chapter KoR Email
example@example.com
This form must be electronically submitted to the Western Province Keeper of Records no later than 25 days prior to the Council meeting. For questions, email: Keeper of Records Office

NOTE: THE CREDENTIALS COMMITTEE WILL VERIFY CREDENTIALS PRIOR TO BALLOTING.
Administrative Only | Approvers
PP Name:*
PP Email:*
example@example.com
PKoR Name:*
PKoR Email:*
example@example.com
PAKoR Name:*
PAKoR Email:*
example@example.com
PAKoE:*
PAKoE Email:*
example@example.com
Western Province, Keeper of Records:*
PKoR Office Email:*
example@example.com
Credentials Committee Chairman
Credentials Committee Chairman Email:*

Submitter Review

For Proxy Representatives
Review Before Submission

Please carefully review all responses entered above for completeness and accuracy. All email addresses must be accurate, as errors may delay credentialing or invalidate the submission.
Page 2

Submitter Name: {submittername}

Submitter Email: {submitterEmail}

Submitter Member ID: {submitterid}

Registering Chapter: {registering_chapter}

Registration Type: {regtype}

Phone Number: {subphoneNumber}

Chapter Type: {chaptertype}

Page 3

Chapter Polemarch Name: {chapterPolemarch_name}

Chapter Polemarch Email: {chappolemarch_email}

Chapter Vice Polemarch Name: {vicePolemarch_name}

Chapter Vice Polemarch Email: {vicePolemarch_email}

Chapter KoR Name: {chapkor_name}

Chapter KoR Email: {chapkor_email}

Chapter Advisor Name: {name300}

Chapter Advisor Email: {chapterAdvisor}

Page 5

Proxy Information:

Proxy Voter Name: {proxyvoter_Name}

Proxy Voter Email: {proxyvoter_Email}

Proxying Chapter: {proxyingChapter_Dropdown}
By selecting this option, I acknowledge that I have reviewed the information presented above and confirm that it is accurate, complete, and submitted in good faith. I understand that this information may be relied upon for official review, approval, or record-keeping purposes:*

YesNo

Submitter Review

For Delegates/Alternates
Review Before Submission

Please carefully review all responses entered above for completeness and accuracy. All email addresses must be accurate, as errors may delay credentialing or invalidate the submission.
Page 2

Submitter Name: {submittername}

Submitter Email: {submitterEmail}

Submitter Member ID: {submitterid}

Registering Chapter: {regchapter}

Registration Type: {regtype}

Phone Number: {subphoneNumber}

Chapter Type: {chaptertype}

Page 3

Chapter Polemarch Name: {chapterPolemarch_name}

Chapter Polemarch Email: {chappolemarch_email}

Chapter Vice Polemarch Name: {vicePolemarch_name}

Chapter Vice Polemarch Email: {vicePolemarch_email}

Chapter KoR Name: {chapkor_name}

Chapter KoR Email: {chapkor_email}

Chapter Advisor Name: {chapadvisor_name}

Chapter Advisor Email: {chapteradvisor_email}

Page 4

Delegate1 Name: {delegate1_Name}

Delegate 1 Member ID: {delegate1_ID}

Delegate 1 Email: {delegate1_email}

Delegate 2 Name: {delegate2_Name}

Delegate 2 Member ID: {delegate2_ID}

Delegate 2 Email: {delegate2_email}

Delegate 3 Name: {delegate3_Name}

Delegate 3 Member ID: {delegate3_ID}

Delegate 3 Email: {delegate3_email}

Alternate 1 Name: {alternate1_Name}

Alternate 1 Member ID: {alternate1_ID}

Alternate 1 Email: {alternate1_Email}

Alternate 2 Name: {alternate2_Name}

Alternate 2 Member ID: {alternate2_ID}

Alternate 2 Email: {alternate2_Email}

Alternate 3 Name: {alternate3_Name}

Alternate 3 Member ID: {alternate3_ID}

Alternate 3 Email: {alternate3_Email}
By selecting this option, I acknowledge that I have reviewed the information presented above and confirm that it is accurate, complete, and submitted in good faith. I understand that this information may be relied upon for official review, approval, or record-keeping purposes:*

YesNo
Should be Empty:

Delegation Registration Form

Submitter Information

Chapter Officers

Delegate | Alternate Appointment

Delegates

Alternates

PROXY FORM

Proxy Vote Information

Approvals

Administrative Only | Approvers

Submitter Review

Submitter Review