2011-12 AAPA House of Delegates Notification Form

2011-12 AAPA HOUSE OF DELEGATES NOTIFICATION FORM

This form certifies that the following organization has elected the following AAPA fellow members as delegates and alternates to the House of Delegates.

* First Name:

* Last Name:

* PA Organization:

Today's Date:

* E-mail:

Please submit only as many delegates as are apportioned to your organization.

Click here if you are unsure of your apportionment.

List Chief Delegate:

	Name	E-Mail
1.

List Delegates:

	Name	E-Mail
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

List Alternates:

	Name	E-Mail
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Do any of your representatives have special requirements such as wheelchair/scooter access in the House that we can accommodate? If so, please explain below.

Thank-you for completing the AAPA House of Delegates Notification form. If you have any questions, contact Tom Shoemaker at tshoemaker@aapa.org.

* Indicates Response Required