2023 DOP District 6 Convention Delegate Form
Kindly complete the form below to submit delegates and alternates for the convention to be held on Saturday, June 17, 2023, by no later than June 1, 2023.

If no information is available, please indicate N/A. Please provide an e-mail address for all delegates and alternates.
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Email *
Chapter Name and No. *
Number of Attendees *
Delegate 1 - Member # *
Delegate 1 - Name *
Delegate 1 - Address *
Delegate 1 - Email address *
Delegate 2 - Member # *
Delegate 2 - Name *
Delegate 2 - Address *
Delegate 2 - Email address
Delegate 3 - Member # *
Delegate 3 - Name *
Delegate 3 - Address *
Delegate 3 - Email address
Delegate 4 - Member # *
Delegate 4 - Name *
Delegate 4 - Address *
Delegate 4 - Email address
Delegate 5 - Member # *
Delegate 5 - Name *
Delegate 5 - Address *
Delegate 5 - Email address
Delegate 6 - Member # *
Delegate 6 - Name *
Delegate 6 - Address *
Delegate 6 - Email address
Alternate 1 - Member #
Alternate 1 - Name
Alternate 1 - Address
Alternate 1 - Email address
Alternate 2 - Member #
Alternate 2 - Name
Alternate 2 - Address
Alternate 2 - Email address
Alternate 3 - Member #
Alternate 3 - Name
Alternate 3 - Address
Alternate 3 - Email address
Alternate 4 - Member #
Alternate 4 - Name
Alternate 4 - Address
Alternate 4 - Email address
Alternate 5 - Member #
Alternate 5 - Name
Alternate 5 - Address
Alternate 5 - Email address
Alternate 6 - Member #
Alternate 6 - Name
Alternate 6 - Address
Alternate 6 - Email address
Grand Lodge, Past Grand Lodge, District Governor, Past District Governor, or District Lodge Officer. Please indicate your name and title. 
Member # and E-Mail
Grand Lodge, Past Grand Lodge, District Governor, Past District Governor, or District Lodge Officer. Please indicate your name and title. 
Member # and E-Mail
Grand Lodge, Past Grand Lodge, District Governor, Past District Governor, or District Lodge Officer. Please indicate your name and title.
Member # and E-Mail
Please type your name below, which will serve as the electronic signature attesting to the information submitted on behalf of the President and Secretary. *
After completing the above delegate registration form for the 2023 convention, kindly submit the appropriate fees per member by check payable to DOP District 6, c/o Alexandra Davis, District Treasurer, 59 Rolling Brook Dr., Clifton Park, NY 12065. The deadline to receive the delegate form and fees is Thursday, June 1, 2023. 

In order to be a delegate or alternate you must be in good standing by paying your chapter dues through 2023 & have attended 4 meetings. The chapter must have paid all their obligations to both District & National. Please note that any chapters with 8-14 members can only send 4 delegates.

Please note that Grand Lodge, Past Grand Lodge, District Governor, Past District Governor, or District Lodge Officer aren't included in the chapter delegate count. 

Any chapters who have not yet paid their $4 per member district per capita, should immediately forward the amount payable to DOP District 6, c/o Alexandra Davis, District Treasurer, 59 Rolling Brook Dr., Clifton Park, NY 12065.
A copy of your responses will be emailed to the address you provided.
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