2023 NCIL Board of Directors Nomination Form

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

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* 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)

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* 2. NOMINEE Contact Information

Nominee Name *

Company

City/Town

State/Province

Nominee Email Address *

Phone Number

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* 3. NOMINEE Region

Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Region 2: New Jersey, New York, Puerto Rico, Virgin Islands

Region 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region 7: Iowa, Kansas, Missouri, Nebraska

Region 8: Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region 9: Arizona, California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands

Region 10: Alaska, Idaho, Oregon, Washington

Other (please specify):

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

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

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

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

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

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* 8. Why does this person want to serve on the NCIL Board?

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* 9. Nominator Contact Information

Nominator Name *

City/Town *

State/Province *

ZIP/Postal Code

Email Address *

Phone Number

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* 10. Nominator Membership Type

Individual

CIL / SILC / Organization

Other organization

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* 11. Electronic Signature

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