MSFA Convention Registration

Representing the Volunteer Fire, Rescue, and Emergency Medical Services Personnel

Electronic 2013 C R E D E N T I A L S F O R M

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This Form should be completed by the Company President or Secretary

To the Secretary of the Maryland State Firemen's Association: At the Regular Company Meeting of:,

,Inc.,

in County, Maryland, the delegates and alternates listed below were elected or appointed to represent the company during the next year and at the next Annual Convention of the MSFA:

OFFICERS

President        : President's Email:

Vice President:    VP Email           :

Secretary        : Secretary Email   :

Treasurer        : Treasurer Email   :

Chief              : Chief's Email        :

Chaplain        : Chaplain's Email    :

Delegates

Chair            : Chair Email            :

Delegate2     : Delegate2's Email   :

Delegate3    : Delegate3's Email   :

Delegate4    : Delegate4's Email    :

Delegate5    : Delegate5's Email   :

Alternates

Alternate1   : Alternate1's Email   :

Alternate2   : Alternate2's Email   :

Alternate3   : Alternate3's Email   :

Alternate4   : Alternate4's Emai     :

Alternate5   : Alternate5's Email    :

Full Name of Company :

Mailing address of Company :

Town :    State :     Zip :

Street Address if Different:

Phone :    Fax :

Web Site :

Date :

Person Completing Form :    Completer's Email :

Title / rank of person completing form President, Secretary,etc.  : Completer's Phone :

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Pressing Submit Will Save your information Directly to MSFA without further submission