Delegate Registration Form
Note: All Alternate Delegates must be financially active to represent a chapter during the 2020 Gulf Coast Regional Conference. Additionally, Chapter must be in good standing to include all Financial Assessments having been met in full. Any chapter not meeting any of the above requirements will be refused representation for the duration of the conference procedures.
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Email *
Submitter's First and Last Name *
Chapter (spell out each chapter name) *
Primary Delegate First and Last Name *
Primary Delegate PBS Member # *
Primary Delegate Phone Number *
Alternate Delegate First and Last Name *
Alternate  Delegate PBS Member # *
Alternate  Delegate Phone Number *
Chapter President First and Last Name *
Chapter President PBS Member # *
Chapter President Phone Number *
Chapter Secretary First and Last Name *
Chapter Secretary PBS Member # *
Chapter Secretary Phone Number *
A copy of your responses will be emailed to the address you provided.
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