2018 Delegate Registration

Note: The below is for DELEGATES only to register for the Council of Representatives.

All Delegates and Alternate Delegates must also register for the Conference seperately at hartford.nad.org.

State Association / Affiliate*

City*

State*

How many delegates

Delegate #1*

First NameLast Name

Delegate #1 NAD Membership

Delegate #1 Membership Expiration Date

MonthDayYear

Delegate #1 Experience*

Delegate #1 Position*

Delegate #1 E-mail*

Delegate #1 Text Number

Area CodePhone Number

Delegate #2

First NameLast Name

Delegate #2 NAD Membership

Delegate #2 Membership Expiration Date

MonthDayYear

Delegate #2 Experience

Delegate #2 Position

Delegate #2 E-mail

Delegate #2 Text Number

Area CodePhone Number

Delegate #3

First NameLast Name

Delegate #3 NAD Membership

Delegate #3 Membership Expiration Date

MonthDayYear

Delegate #3 Experience

Delegate #3 Position

Delegate #3 E-mail

Delegate #3 Text Number

Area CodePhone Number

Delegate #4

First NameLast Name

Delegate #4 NAD Membership

Delegate #4 Membership Expiration Date

MonthDayYear

Delegate #4 Experience

Delegate #4 Position

Delegate #4 E-mail

Delegate #4 Text Number

Area CodePhone Number

Delegate #5

First NameLast Name

Delegate #5 NAD Membership

Delegate #5 Membership Expiration Date

MonthDayYear

Delegate #5 Experience

Delegate #5 Position

Delegate #5 E-mail

Delegate #5 Text Number

Area CodePhone Number

Delegate #6

First NameLast Name

Delegate #6 NAD Membership

Delegate #6 Membership Expiration Date

MonthDayYear

Delegate #6 Experience

Delegate #6 Position

Delegate #6 E-mail

Delegate #6 Text Number

Area CodePhone Number

Will you have any Alternate Delegates?

Note: The below is for ALTERNATE Delegates only to register for the Council of Representatives.

State Association / Affiliate

City

State

How many alternate delegates

Alt. Delegate #1

First NameLast Name

Alt. Delegate #1 NAD Membership

Alt. Delegate #1 Membership Expiration Date

MonthDayYear

Alt. Delegate #1 Experience

Alt. Delegate #1 Position

Alt. Delegate #1 E-mail

Alt. Delegate #1 Text Number

Area CodePhone Number

Alt. Delegate #2

First NameLast Name

Alt. Delegate #2 NAD Membership

Alt. Delegate #2 Membership Expiration Date

MonthDayYear

Alt. Delegate #2 Experience

Alt. Delegate #2 Position

Alt. Delegate #2 E-mail

Alt. Delegate #2 Text Number

Area CodePhone Number

Alt. Delegate #3

First NameLast Name

Alt. Delegate #3 NAD Membership

Alt. Delegate #3 Membership Expiration Date

MonthDayYear

Alt. Delegate #3 Experience

Alt. Delegate #3 Position

Alt. Delegate #3 E-mail

Alt. Delegate #3 Text Number

Area CodePhone Number

Alt. Delegate #4

First NameLast Name

Alt. Delegate #4 NAD Membership

Alt. Delegate #4 Membership Expiration Date

MonthDayYear

Alt. Delegate #4 Experience

Alt. Delegate #4 Position

Alt. Delegate #4 E-mail

Alt. Delegate #4 Text Number

Area CodePhone Number

Alt. Delegate #5

First NameLast Name

Alt. Delegate #5 NAD Membership

Alt. Delegate #5 Membership Expiration Date

MonthDayYear

Alt. Delegate #5 Experience

Alt. Delegate #5 Position

Alt. Delegate #5 E-mail

Alt. Delegate #5 Text Number

Area CodePhone Number

Alt. Delegate #6

First NameLast Name

Alt. Delegate #6 NAD Membership

Alt. Delegate #6 Membership Expiration Date

MonthDayYear

Alt. Delegate #6 Experience

Alt. Delegate #6 Position

Alt. Delegate #6 E-mail

Alt. Delegate #6 Text Number

Area CodePhone Number

President*

First NameLast Name

President's E-mail*

Deadline: May 1, 2018. Incomplete or late forms will not be accepted.

Email jerry.nelson@nad.org if you have any questions.