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* * * * * * * * * * * ** * * * * * * * * * * * * * * ** * * ** 2012 NDGOP CONVENTION

BISMARCK CIVIC CEN I ER MARCH 30 - APRIL 1
Registration Fees Must Accompany This Form District #:

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Registration Information: Please provide the following information

Last Name Address City Cell Phone Number Email Address

First Name

State

Zip Code

Registration Data: I certify that I am a (please choose all that apply) Delegate Legislator Alternate Candidate District Chair Staff Guest

Registration Fees: Please choose one of the following ****Must be postmarked by Monday, March 26 No Exceptions***" Delegate ($80) Alternate ($60) 30 yrs and under ($40)

Convention Events: Indicate number of tickets/total for each event Saturday, March 31 Saturday Night Rock - $15/person (Paid Members of the NDGOP Admitted Free) Sunday, April 1 First Lady's Prayer Breakfast - $15/person Total Registration Fees (from above) and Events Amount Enclosed
Please make check payable to ND Republican State Convention, or complete credit information:

Governor's Club Dinner will be held on Friday, March 30. Contact Marsha Reimnitz at 701-250-7001 for more information. Visa Credit Card # Name on card: Mastercard Discover

American Express Exp Date Signature:

District Chair Signature

Date

FORM MUST BE APPROVED BY THE DISTRICT CHAIR BEFORE IT WILL BE PROCESSED (see the back of this form for process and information) SEND ALL FORMS TO: NDGOP, PO BOX 1917, BISMARCK, ND 58502

DELEGATE APPLICATION FORM INFORMATION AND PROCESS

Process:
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To become a delegate for the convention, please complete the entire application.

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The completed form must be approved by the District Chair before it will be processed through registration (postmarked by Monday, March 26 no exceptions)

* To verify District Chair information, please check the party website (http://www.northdakotaqop.orq/about/district-chairs/) or call headquarters and ask for Dee (701-255-0030).

Must be accompanied by registration fees.

Please make a copy of this form for your records.

MAIL FORM TO: NDGOP, PO Box 1917, Bismarck, ND 58502

Information:
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pit For paid members of the NDGOP, admission to the

Saturday Night Rock is free.

State party dues are renewed on an annual basis, beginning the first of the year. In order to get free admission to the Saturday Night Rock, please renew your dues. You can renew your dues via the party website (www.ndgop.org ).

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The Governor's Club Dinner will be held on Friday, March 30. If you would like to attend, please contact Marsha Reimnitz at 701-250-7001 or marsha@dalrympleforgovernor.com Governor's Club dues are renewed based on when you originally joined (anniversary date). Please note that the Governor's Club Dinner registration is separate from convention registration.