2023 NCIL Board of Directors Nomination Form Survey

Please check with the nominee regarding their willingness to run prior to making a nomination and provide them with a copy of the position description and memo from the NCIL Board regarding obligations of NCIL Board members.

Nomination Deadline: May 19, 2023

1.Position Being Nominated For:

President

Treasurer

Member-At-Large

Region 1 Representative (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont)

Region 3 Representative (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia)

Region 5 Representative (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)

Region 7 Representative (Iowa, Kansas, Missouri, Nebraska)

Region 9 Representative (Arizona, California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands)

2.NOMINEE Contact Information(Required.)

Nominee Name

Company

City/Town

State/Province

Nominee Email Address

Phone Number

NOMINATOR: As the nominator of this prospective board member, please work with the nominee to complete the following information:

4.What is the length of time they have been an individual member of NCIL?(Required.)

5.Have they served on any NCIL Committees, Subcommittees or Task Forces? If so, which one(s)?(Required.)

6.What do they consider to be their greatest accomplishment as an advocate during their involvement in Independent Living?(Required.)

7.What skills, talents and resources will they bring to the NCIL Board?(Required.)

8.Why does this person want to serve on the NCIL Board? (Required.)

9.Nominator Contact Information(Required.)

Nominator Name

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

10.Nominator Membership Type (Required.)

Individual

CIL / SILC / Organization

Other organization

11.Electronic Signature(Required.)

I affirm that I contacted the nominee and that they have agreed to run