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GROUP/ALTERNATE GROUP SERVICE REPRESENTATIVE
SUBSTITUTION FORM
For purposes of group representation at the Assembly, the GSR (or Alternate GSR) submits
the following Family Group Member name, who will be acting on behalf of the group in place
of the GSR/Alternate GSR:
Name (Please Print) ____________________________________________________
Signature _____________________________________________________
Family Group Represented (Please include City, State)
_____________________________________________________
Submitted by*:
Name (Please Print) ____________________________________________________________
Midwest Region Family Group Position: [ ] GSR [ ] Alternate GSR
Signature ________________________________________ Date ______________________
IMPORTANT NOTE: In order for the Substitute to have voting privileges at the Assembly, the
form must be completed with the GSR or Alternate GSR’s signature and filed with the
Region’s Secretary prior to any vote being taken. This document may be submitted as either
a scanned copy or a hard copy.