Name:_______________________ Council or Affiliation___________________
Address:_______________________ City_________ State___ Zip_________
Phone: (H):________________ (W):________________(Cell):________________
Email address:_______________________
Current HI-USA membership number:_________________
Approximate number of Years with HI-USA:________
Roles and committees within HI-USA that you have served and/or participated in:
____________________________________________________________________
Other non-profit board experience:__________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Complete one of the following:
1.For Council President: Briefly describe your experiences and abilities that relate directly to those required for the position, please attach resume.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Alaska Council HI-USA
2.For Council Vice President: Briefly describe your experiences and abilities that relate directly to those required for the position, please attach resume. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3.For Council Secretary Treasurer: Briefly describe your experiences and abilities that relate directly to those required for the position, please attach resume.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4.For Council At-large: Briefly describe your experiences and abilities that relate directly to those required for the position, please attach resume.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Candidates Statement: (I would like to help the Alaska Council in the following ways during my term):
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Conflict of interest statement: As a candidate for the position of an Alaska Council Officer or At-large member, I attest that I am not an employee of HI-USA, Inc., and its chartered, licensed, and other subsidiary units, and its licensees which are not operated as public charities, or any of its chartered regional or local councils. I further attest that I would have no conflicts of interest if elected as an Alaska Council Officer.
I further attest that the above information is correct and accurate.
____________________________________________ _______________
Candidate’s Signature Date
Please submit this form either electronically or write
Sharon--
Nominating Committee Chair
Sharon White-Wheeler
P.O. Box 81
Hope, AK 99605
Phone
1-907-276-4123
or fax-1-907-276-4123
for more information.