* 1. Name

* 3. Street Address

* 4. City

* 6. Zip

* 7. Phone number (personal)

* 8. Email address (personal)

* 9. Which committees would you like to be on at convention? (Please rank in order of preference.)

* 10. Would you like to be on any special committees at convention?

* 11. Do you have any dietary restrictions? (Please select all that apply.)

* 12. Full names of additional guests for the Saturday evening awards banquet ($55 each)

* 13. I understand that the convention registration fee is $75 per delegate/alternate, and that this fee includes the Saturday awards banquet. Additional guests to the Saturday awards banquet are $55 each. Checks must be made payable to AFT-Oregon, postmarked by March 22, 2017, and sent to the office at 10228 SW Capitol Hwy, Portland OR 97219.

* 14. By submitting this form electronically I am verifying that this information has been certified by my local.

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