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NACo 2015 <br />Credentials (Voting) <br />N A D National Assoeiatron of Counties <br />Form � <br />► Please complete and RETURN FORM BY JUNE 19.201 S to: <br />Credentials Committee / NACo / Attn: Alex Koroknay- Palicz <br />25 Massachusetts Avenue, NW, Suite 500 /Washington, DC 20001 <br />► You may also fax this form to 202.393.2630 ... or scan and e -mail this form to: akpalicz @naco.org ... or have the voting <br />delegate(s) carry it with him /her to the conference and present it at the Credentials Desk. <br />► If you do not plan on registering for the 2015 Annual Conference, there is no need to fill out and return this form. <br />Your county /parish /borough MUST have at least one paid conference registration to be able to vote. <br />► If you are registering for credentials on -site, you will need to fill out the on -site ballot form. By signing this form you are declaring <br />that you and the other conference attendees from your county have agreed that you are the voting delegate for your county. <br />► If your ballot is not picked up at the 2015 Annual Conference the President of your State Association will pick up and <br />cast your county's votes unless you check the box below. <br />❑ If my ballot is not picked up, I DO NOT AUTHORIZE my state association to pickup or cast my county's vote. I <br />understand that my county's votes will NOT be cast if I select this option. <br />Please type or print in block letters. <br />County / Parish / Borough <br />Name your county /parishfborough "s delegate(s) <br />Please assign a delegate from your county /parish /borough. <br />First Name <br />Last Name <br />State <br />N C <br />1. S JT E I P I H E N M O R R I S <br />Job Title /Position <br />C H A T R M A N <br />First Name Last Name <br />D I I A N E I I I I I I H O N E Y C U T T <br />Job Title /Position <br />C O M M I S S I 1 O 1 N I E R <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 />STEPHEN M. MORRIS <br />Print Name <br />Cell Number <br />CHAIRMAN, BOARD OF COMMISSIONER §, �_ _, __ <br />Title <br />F -1 Page 59 <br />