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NATIONAL <br />ASSOCIATION <br />f COUNTIES <br />2016 <br />CREDENTIALS <br />VOTING <br />PLEASE TYPE OR PRINT IN BLOCK LETTERS. <br />Please complete and <br />RETURN FORM BY JULY 1, <br />2016 to: <br />Credentials Committee 1 NACo <br />Attn: Alex Koroknay- Palicz <br />25 Massachusetts Avenue, NW, <br />Suite 500 <br />Washington, DC 20001 <br />You may also fax this form to <br />866.370.9421.. or scan and e-mail <br />this form to: akpaiicz@naco.org... <br />or have the voting delegate(s) carry <br />it with him /her to the NACo <br />conference and present it at the <br />Credentials Desk. <br />If you do not plan on registering for the <br />2016 Annual Conference, there is no <br />need to fill out and return this form. <br />Your county /parish /borough MUST <br />have at least one paid conference <br />registration to be able to vote. <br />By signing this form you are declaring <br />that you and the other conference <br />attendees from your county have <br />agreed that you are the voting delegate <br />for your county. <br />If your ballot is not picked up at <br />the 2016 Annual Conference the <br />President of your State Association <br />will pick up and cast your county's <br />votes unless you check the box <br />below <br />If my ballot is not picked up, <br />1 DO NOT AUTHORIZE my <br />state association to pick up or cast <br />my county's vote. I understand that <br />my county's votes will NOT be cast <br />if I select this option. <br />County/ Parish/ Borough State <br />C B A R R U S I I JQ N T Y I I I I I I I I N C <br />Name your county / parish /borough's delegate (s) <br />Designated County Delegate <br />First Name Last Name <br />S T E P H E N M O R R I S <br />Job Title/ Description <br />C H A I R M A N <br />County Alternate <br />First Name <br />Last Name <br />Job Title/ Description <br />Please note: This form must be signed by the CHIEF ELECTED OFFICIAL from your county. <br />Submissions without an appropriate signature will not be accepted <br />Signature of Chief Elected official Date <br />(Board President/ Chair/ elected County Executive / Judge / Mayor) <br />Cell Number <br />STEPHEN M. MORRIS CHAIRMAN, BOARD OF CO <br />Print Name Title <br />F -2 Page 78 <br />