Your Name:   
Your Phone:     Your Email: 

Please provide the following information about the person you are nominating.

Nominee's Name: 
Address: 
Phone:      Fax: 
Email:  

Nominee's Place of Employment: 
Title: 
Work Address: 
Work Phone:     Fax: 
Spouse/Partner Name: 

Other Boards or Organizations the Nominee is affiliated with:

Brief Bio of Nominee:

Have you discussed the responsibilities of the board of directors with the nominee? Select Yes No