All cumulative Electric record book winners must complete the following information and submit it to your County 4-H Agent prior to the April 15th deadline so that it may be forwarded with the total county registration materials. Please print or type your information on these forms.

Territory: Progress Energy___ Duke___ DNC Power___ County___________________

Name_____________________________________ Age_______

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)

Previous territory winner: Yes ___ No___

Territory prizes received and in what year?

_______________________ ____________________________

_______________________ ____________________________

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:

Cumulative Electric Record Book Winner signature: __________________________________________

Agent's name:_____________________________________

Leader's name:____________________________________