Free Nomination for Gubernatorial Appointment - Virginia

NOMINATION FOR GUBERNATORIAL APPOINTMENT (To be completed by nominating organization. PLEASE ATTACH RESUME AND LETTER)
Nomination for: ________________________________________________________________________ Name of Board Nominated by: _________________________________________________________________________ Nominating Organization Position: ______________________________________________________________________________ As a Member, i.e. Area/Region/District/Industry Representative Name: ________________________________________________________________________________ First Middle Last Home Address: _________________________________________________________________________ Street City State ZIP Telephone ­ Home: (_____) __________ Work: (_____) _________ Fax: (_____) __________ Mobile: (_____) ____________ Email (please print):___________________________________________ Present Employment Position: _____________________________________________________________ Name of Employer/Firm: _________________________________________________________________ Type of Business: _______________________________________________________________________ Business Address: _______________________________________________________________________ Street City State ZIP Member of Nominating Organization? ___ YES ___ NO If "YES", what position in the organization? __________________________________________________ Education: _____________________________________________________________________________ The following information is optional Sex (M/F) Date of Birth Place of Birth

Ethnic Group

American Indian

Asian

Black

Hispanic

Other

White

Describe the experience, interests and other background information about this nominee that would qualify this person to serve on the Board. Attach additional sheets, if necessary, to support his/her qualifications. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________