REGION/CHAPTER PROXY
I appoint ______________________________________ as proxy holder with full power to vote for and in behalf of the undersigned at any scheduled meeting of this Region/Chapter (cross one out). This proxy will remain in effe ct as long as I am a member of the Region/Chapter (cross one out), or until revoked by me. In the event that I am present for a Region/Chapter (cross one out) meeting, this proxy is invalid for that meeting.
Date

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Name of Member

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Signature of Member

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USAWOA Member No.

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USAWOA FORM 500-11-R DEC 87

Professional - Representation - Recognition