Proxy Form

Must be completed by chapter's secretary and regent

Due 21 Days before Business Meeting (Jan 28th)

The undersigned officers (Regent & Secretary), acting under the direction of their membership of Kappa Psi Pharmaceutical Fraternity bestow their voting privileges on the duly elected delegates of the chapter named below for the Northwest Province Winter Conclave Meeting.  

Select the Collegiate or Graduate Chapter you are an officer of.
Please select the chapter you wish to cast your votes on your behalf.
Submitter Info
Both the Secretary and Regent must submit this Proxy Form on behalf of their chapter.
Regent (Undersigned Regent) *
Regent (Undersigned Regent)
Regent's Name
Secretary (Undersigned Regent) *
Secretary (Undersigned Regent)
Secretary's Name
Date *
Date
Please enter today's date.
Confirmation *
By checking the boxes below, it will act as the digital signature of the Regent and Secretary and as the designation of proxy.