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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.