USA Judo National Assembly
Group A Registration
Group A Name
Date
Names in Delegation:
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Name
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USA
Judo Member Number
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Exp Date of USA Judo membership
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Head
Delegates
Initials
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Email Address
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Head of
Delegation
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1st
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2nd
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3rd
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4th
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5th
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Alternate 1
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6th
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Alternate 2
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7th
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Alternate 3
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8th
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(List possible delegates in ranking order)
Only the Head of Delegation will be able to approve the actual delegates who will be allowed voting rights in the election.
Signature of President
Signature of Secretary
Contact Email
Contact Cell Phone Number
Voting instructions will be emailed to voters prior to the election.
THIS FORM MUST BE EMAILED TO SHERRIE WILSON NO LATER THAN OCTOBER 1, 2012
at
Via email: Sherrie.wilson@usajudo.us
Via Postal: USA Judo/Sherrie Wilson, One Olympic Plaza, Colorado Springs, CO 80909
Via Fax: 719.866.4733