Member Proxy Authorization Form

Proxy voting is only authorized for committee officer elections conducted at an in-person meeting. Proxy voting is not permitted for any other vote conducted under the auspices of the corporation. If a member's primary and alternate representatives are both unable to attend the committee meeting at which an officer election will be conducted, the member's primary representative may authorize another member representative to exercise the member's voting privilege. To authorize a proxy, the member's primary representative must properly complete this online form prior to the record date for the ballot, which is seven (7) days prior to the vote. The proxy shall be in effect once X12 staff verifies the assignment form. The member's primary representative and the designated proxy holder shall be notified of the outcome of the X12 staff verification.

By completing and submitting this form, I attest that neither I, the member's primary representative, nor the member's alternate representative, will be present for the upcoming committee officer elections scheduled for the next Standing meeting. In our absence, the X12 member representative named below shall be authorized to vote on behalf of the member. I understand that this proxy assignment shall not be effective until the information has been verified by X12 staff. Once verified, these proxy voting privileges shall be in effect for the Accredited Standards Committee (ASC) Officer Elections scheduled for September 25, 2017.

Fields Marked with a * are required
*X12 Member
*Name of the X12 Member's Primary Representative
*Email Address of the X12 Member's Primary Representative
*Name of the X12 Member Representative to be Designated with Proxy Voting Privileges
*Email Address of the X12 Member Representative to be Designated with Proxy Voting Privileges

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