2017-2019 NCA Regional Sponsor Representative Application Survey

1.Contact Information:(Required.)

Name:

Company:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

2.For how long have you been a member of the National CACFP Sponsors Association?

Less than 2 Years

2-5 Years

6-10 Years

Over 10 Years

Other (please specify)

3.USDA Region for which you are applying to serve as representative?(Required.)

Mid-Atlantic Region (MARO): Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Puerto Rico, Virginia, Virgin Islands, West Virginia

Midwest Region (MWRO): Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Mountain Plains Region (MPRO): Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, South Dakota, Utah, Wyoming

Northeast Region (NERO): Connecticut, Maine Massachusetts, New Hampshire, New York, Rhode Island, Vermont

Southeast Region (SERO): Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Southwest Region (SWRO): Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Western Region (WRO): Alaska, Arizona, California, Guam, Hawaii, Idaho, Nevada, Oregon, Washington

4.What is the job title for your current position?(Required.)

5.About how long have you been in your current position?(Required.)

Years

Months

6.Qualifications to serve as a Regional Representative for the National CACFP Sponsors Association?(Required.)

7.Current and/or previous advisory positions on which you have served?(Required.)

Board, Position Held, Years Served:

8.Does your organization support your desire to serve in this position with the National CACFP Sponsors Association?(Required.)

Yes

No

9.Do you have any personal commitments that would prevent you from attending the NCA Annual Conference each April and serving as Regional Roundtable Moderator?(Required.)

No

Yes

Yes, because. . .

10.If appointed, will you devote the time, energy, and resources to serve in this capacity? (Required.)

Yes

No

Explain:

11.What are your personal long-range goals for the National CACFP Sponsors Association?(Required.)

12.What do you think Regional Sponsor Representatives could do to enhance the work of the National CACFP Sponsors Association?

14.In what capacity did you participate in a past conference?

Attendee

Workshop Presenter

Conference Committee

Conference Chair