Interest Group Plaque Request Form

Submission Deadline: September 15

Plaque requests submitted by the deadline will be shipped to the Annual Convention for pick-up and distribution. Requests received after the deadline will be mailed directly to recipients after the Convention.

Step 1 of 2

Submitter Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Interest Group Position(Required)

Plaque Details

Interest Group Name(Required)

How many plaques you are requesting?(Required)

Note, each plaque will result in a $50 deduction from the Interest Group’s budget.

Plaque Details(Required)

Use the (+/-) button to add or remove additional rows. Be sure to carefully review and spell-check each field before submitting. Any errors resulting from submitter mistakes that require a new plaque will incur an additional $30 charge.

Award

Recipient(s) Name

Title/ In Recognition Of

Special Instructions or Comments