Southern National Congress Delegate Application
Please Read Carefully: Information submitted in your application will be forwarded to the registrar for your state of residence for consideration. The decision regarding your application by your state delegation is final. Only applications from applicants residing in the following states shall be considered for delegate positions: Virginia, Maryland, North Carolina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, Tennessee, Kentucky, Missouri, Arkansas, and Texas. Applications should only be submitted ONCE. Incomplete applications will not be considered.

General Information:

Name:  Mr. Mrs. Miss Dr. Rev. Pastor    First       Last

Mailing Address:  Street 

City or Town:   State: Alabama Arkansas Florida Georgia Kentucky Louisiana Maryland Missouri Mississippi North Carolina South Carolina Tennessee Texas Virginia   Zip Code:

Email:

Phone:

Qualification:

Are you at least 18 years of age?  Yes  No

Do you warrant that you are of good moral character, have no criminal record, and have never been convicted of a mal in se crime; that is, a thing “evil in itself,” (murder, rape, arson, kidnapping, violent assault, armed robbery, etc.)  Yes

 I have read and understand the Southern National Congress statement on qualifications for Participation  Yes

Please tell us about any talents, skills, previous experience, or educational attainment that you believe would be an asset for the Southern National Congress. Please restrict your comments to information that will be helpful in your state delegation's consideration of your application: