DELEGATE VOTING CREDENTIALS FOR WISCONSIN ASSOCIATION - YEAR 2004

CLUB NAME:_______________________________________________________________

DELEGATE NAME:__________________________________________________________

DELEGATE ADDRESS:_______________________________________________________

CITY:________________________________ STATE:_______ ZIP:____________________

PHONE:____________________________________

E-MAIL ADDRESS:__________________________________________________________

CLUB PRESIDENT SIGNATURE:_______________________________________________

CLUB SECRETARY SIGNATURE: ______________________________________________

The Delegate is to remain the same person for one year or club must submit new delegate name to Board of Wisconsin prior to next meeting. Per Article VIII, Section 2 of the Bylaws.