December, 2014 GA Meeting Registration Form

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PLEASE NOTE
This form is to be used to register representatives for the December 7, 2014 General Assembly meeting. In order for your kehilla to have its full voting strength, registration must be completed by 3:00 pm Friday, October 31, 2014. Registration after that date will allow the kehilla a single (1) vote, no matter kehilla size. You MAY change email addresses, etc., but we cannot accept a new registration.
IF you need to make a change in the appointed person, please send a note to surveys@uscj.org.

Full Name of Kehilla (congregation) *

Please use the full, FORMAL name of your kehilla.

Kehilla CITY *

Please put in name of the city where your kehilla is located.

TWO LETTER Kehilla State or Province *

Please use the official *two letter* abbreviation. (e.g., Missouri use MO; Ontario use ON)

Kehilla Postal / Zip Code *

Please provide your kehilla's Post / Zip code.

My kehilla is in District / Region *

Number of Membership Units (families, households) *

How many membership units [not indviduals] are in your kehilla?

Last Name of person COMPLETING this form *

First name of person COMPLETING this form. *

Title or position of person COMPLETING this form *

President or highest ranking officer

Other officer

Executive Director

Other:

Email address of person COMPLETING this form. *

I hereby certify that I am the president or highest officer of the kehilla, that I am authorized to submit this form for the kehilla, and the information is true and correct according to the kehilla's records. *

Yes

Kehilla PRESIDENT last name *

Please complete, EVEN IF it appears above.

Kehilla PRESIDENT first name *

Please complete, EVEN IF it appears above.

Kehilla PRESIDENT email *

Please complete, EVEN if it appears above. Double check spelling!

LAST NAME of Your Kehilla Representative (and Chair of Delegation) *

Please provide the last name of your kehilla's GA representative.

FIRST NAME of your Kehilla Representative (and Chair of Delegation) *

REPRESENTATIVE's email address *

REPRESENTATIVE's STREET Address *

REPRESENTATIVE's CITY *

REPRESENTATIVE's STATE / PROVINCE *

Please use official two letter abbreviation.

REPRESENTATIVE's POSTAL / ZIP Code *

REPRESENTATIVE's POSITION in Kehilla *

President

Vice President

Past President

Other officer

Clergy / staff member

Other:

Representative / Chair of Delegation BEST phone Number

Our respresentative plans to attend the special meeting of the General Assembly _______ *

Using electronic means, such as webex or telephone.

In person.

Other:

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