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Re-Nomination Form for IIABA Committee / Task Force / Entity Board

(for the term beginning Jan. 1, 2027 and ending Dec. 31, 2027)

NOTE: If an individual is being nominated for more than one position, a separate nomination form should be completed for each position.
1.Submitted By:
2.From the State of:
3.Name of Individual Being Re-Nominated
4.Name of Committee, Task Force or Board
NOTE:  Only complete the fields below if there have been changes since last year.
5.Individual's Agency Name
6.Individual Agency's Address
7.Individual's Agency Phone Number
8.Individual's Email Address
9.For an individual who is or has been an IIABA Director and/or officer of the state association, please list his/her dates of service and roles (if there have been changes since last year).