2021 Delegate/Alternate Certification

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Town/City/Ward *

Delegate/Alternate/Ex-officio Information

Are you a Delegate, Alternate, or Ex-Officio? *

Delegate

Alternate

Ex-Officio (Chair, DSC Member, Qualifying Elected Official)

First Name *

Last Name *

Middle Initial

Phone Number *

Email *

Gender *

Date of Birth *

YYYY

Please select all that apply:

Black

Hispanic

Asian-American

Native American

Cape Verdean

White

Lesbian

Gay

Bisexual

Transgender

Nonbinary

Queer+

Disabled/Mobility Restrictions

Listening device needed

Wheelchair needed

Will have service animal

ASL/captioning needed

Thank you for completing your Delegate/Alternate/Ex-Officio Certification Form! If you haven't paid you Delegate/Alternate Fee, please do so here: http://bit.ly/Del-Alt-Payment-Form

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