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Medical Delegate Certification Form AMERICAN MEDICAL STUDENT ASSOCIATION Application Deadline: February 15, 2008
Each chartered medical chapter is allotted 1, 2, 3 or 4 delegates, based on membership numbers. Fill out the number of delegates your chapter has been allotted on the form below. If you do not know how many delegates your chapter has, please fill out all four slots, and we will take the appropriate number of delegates starting from the top. More medical members may register as alternate delegates to sit on the House floor during the business sessions, held on Friday and Saturday, March 14-15, 2008. PLEASE PRINT/TYPE:DELEGATE 1: Name _______________________________________________ AMSA ID No. ___________________ Graduating Year________ Address _____________________________________________ Room/Apt. No. _______________________________________ City/State/Zip _________________________________________ Telephone____________________________________________ Email _______________________________________________ DELEGATE 2: Name _______________________________________________ AMSA ID No. ___________________ Graduating Year________ Address _____________________________________________ Room/Apt. No. _______________________________________ City/State/Zip _________________________________________ Telephone____________________________________________ Email _______________________________________________ DELEGATE 3: Name _______________________________________________ AMSA ID No. ___________________ Graduating Year________ Address _____________________________________________ Room/Apt. No. _______________________________________ City/State/Zip _________________________________________ Telephone____________________________________________ Email _______________________________________________ DELEGATE 4: Name _______________________________________________ AMSA ID No. ___________________ Graduating Year________ Address _____________________________________________ Room/Apt. No. _______________________________________ City/State/Zip _________________________________________ Telephone____________________________________________ Email _______________________________________________ The above is(are) an AMSA medical member(s) and THE DULY ELECTED (or appointed) DELEGATE(S) of the American Medical Student Association Chapter at _____________________________ medical school, and is(are) an active member(s) in good standing of the association, and as such, is (are) authorized to represent the above constituent organization in the deliberations of the House of Delegates of the AMSA. Signature & Date ______________________________________ Return the original copy of this form to the AMSA national office by postmark deadline date of February 15, 2008. After this date, you will need to register onsite at convention with either trustee-at-large, Jennifer Jackson or Lauren Hughes, prior to the HOD's first business session. Retain a copy for your chapter files. The original will be available to the credentials committee at each session of the House of Delegates.
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