| Name:
_______________________________________________________________________________ |
| Address:
_____________________________________________________________________________ |
| City:
____________________________________ | State:
________ |
Zip
Code: ____________ |
| Email
: __________________________________ | Telephone: ____________________________ |
| Subordinate
Grange Name and No.: _______________________________________________________ |
Experience
- Please list the offices you have held in your local, Pomona, Youth, or state
Grange: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ |
| Please
list the offices you are interested in filling in order of preference: |
1st
choice_________________________________ 2nd
Choice________________________________ 3rd
Choice________________________________ |
| Which
Achievement awards have you earned? |
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ |
| What Facts would prevent you from comint to the National Convention other than illness or death? |
| _____________________________________________________________________________________ |
| Have you obtained permission from teachers? _______________________ |
| Have you obtained permission from employers? _______________________ |
| How are you going to pay for the trip? _______________________ |
________________________________________
State Youth Directors Signature. |