["Block and copy" this form beginning with Name of "authorized agent," click here to get your e-mail screen, paste, and send to register your "authorized agent."]

Name of "authorized agent":

Position:

Name of School:

Address:

City:

State:

Zip:

Phone:

County:

NMEA/NSAA Region or District (1, 2, 3, 4, 5, 6), if known:

E-mail:

*School World Wide Web address (URL):

*Filling in the WWW address (URL) will automatically give NMEA permission to link to your school's Web site.

Click here to get your e-mail screen, paste, and send to register your "authorized agent."