NBCSN Liasion Application

State Liaison Application – Participation Expectations

State Liaisons are asked to remain reasonably engaged by responding to communications and participating in outreach efforts when able. To ensure an active and effective program, liaisons with no documented activity or communication for one year may be contacted to confirm continued interest. If inactivity continues, the liaison role may be concluded so the opportunity can be offered to another volunteer.

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* 1. General Information

First Name

Last Name

Credentials

Certificate #

Year of Initial Certification

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* 2. Contact Information

Street Address *

Apt/Suite/Office

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. Employment Information

Employer

Work Position

Work Address

Work City/State/Zip

Work Phone

Work Email

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* 4. Are you replacing a current state liaison in your state?

Yes