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2013 ANNUAL CONVENTION PROXY CERTIFICATION 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 MWBLSA and certified by the Midwest Regional Secretary. To help facilitate the processing and verification process, this form, along with the Certification for Recognized Proxy Holder form, should be emailed to the MWBLSA Regional Secretary at mwblsa.secretary@nblsa.org no later than 5:00 pm on February 5, 2013. After this date, forms must be submitted in person. Anyone bringing these forms to the Convention must submit them to the MWBLSA Regional Secretary at the Convention Registration table at least thirty (30) 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 (visit www.nblsa.org/mwblsaconvention for dates/times): Session 1 ______

Session 2_______

Session 3_______

Session 4_______

For the 2013 Annual Convention of the Midwest 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 mwblsa.secretary@nblsa.org by 5:00 pm on February 5, 2013. Any forms submitted after this date MUST be submitted in person. -----------------------------------------------------------------------------------------------------------------------------------------------------------For use by Director of Membership only: Rcvd Date: __________ Rcvd by: __________ Number of Votes: __________ Verified: __________


2013 ANNUAL CONVENTION CERTIFICATION FOR RECOGNIZED PROXY HOLDER To help facilitate the processing and verification process, this form should be sent to the MWBLSA Regional Secretary at mwblsa.secretary@nblsa.org by 5:00 pm on February 5, 2013. After this date, forms must be submitted in person. Proxy holders bringing these forms to the Convention must submit them to the MWBLSA Regional Secretary at the Convention Registration table at least thirty (30) minutes before the plenary session for which the proxy is required.

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 mwblsa.secretary@nblsa.org by 5:00 pm on February 5, 2013. Any forms submitted after this date MUST be submitted in person.

-----------------------------------------------------------------------------------------------------------------------------------------------------------For use by Director of Membership only: Rcvd Date: __________ Rcvd by: __________ Number of Votes: __________ Verified: __________

Proxy Forms  

Proxy Forms