Please use this form to register your TWO best county delegates for 4-H Electric Congress. These winning delegates should be selected from your county Electric Record Book participants. Please do not omit any information from this form and return it along with the COUNTY DELEGATE REPORT FORM by April 15th to register for 4-H Electric Congress. (Remember, only two delegates can be registered as county delegates) Please print or type your information on these forms.

DELEGATE ONE

Territory: Progress Energy___ Duke___  DNC Power___ County____________________

Name_____________________________________ Age_______ (Minimum Age 11)

Male _________ Female_______

Address______________________________ City ______________ Zip Code __________

Phone (______)___________________

Years in Electric Project____ Previously attended E. C.: No__ Yes___ Years attended: _______

Project completed this year___________ (Project book 1, 2, 3, or 4)

Please list any special needs that may need to be addressed at Congress:

Room accommodations ( Please be specific, i.e. Handicap access, etc)

Special diet:

Medication:

Parent(s):_______________________________________

Parent's work number: Mother's work (_____)________ Father's work (_____)__________

Agent:_____________________________________

DELEGATE TWO

Territory: Progress Energy___ Duke___ DNC Power___ County_____________________

Name____________________________ Age_______ (Minimum Age 11)

Male _________ Female_______

Address______________________________City ________________ Zip Code____________

Phone (____)___________________

Years in Electric Project_____Previously attended E. C.: No__ Yes___ Years attended: ______

Project completed this year___________ (Project book 1, 2, 3, or 4)

Please list any special needs that may need to be addressed at Congress:

Room accommodations ( Please be specific, i.e. Handicap access, etc)

Special diet:

Medication:

Parent(s):_______________________________________

Parent's work number: Mother's work (_____)_________ Father's work (_____)__________

Agent:_____________________________________