Board of Directors Nomination Form

Nominee Contact Info

Question Title

* Contact Information

Name

Organization/Affiliation

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

Question Title

* Low Income Representative: One third of NWICA’s Board of Directors must be made up of representatives of low-income individuals and/or communities (defined as 125% of the Federal Poverty Guideline). Please describe below how the nominee meets the definition of low-income representative:

Question Title

* Please describe any skills or experience the nominee would bring to NWICA’s Board.

Question Title

* Please list any affiliations or organizations the nominee belongs to (for example, membership organizations, professional or civic groups, etc.)

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Organization/Affiliation:

Question Title

* Nomination Submitted By:

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number