First Name: *
Last Name
Organization: *
Title & Department: *
Time in Current Position: *
Work Address:
Street Address
Address Line 2
City
State
Postal / Zip Code Work Phone: *
Number Personal Cell:
Number Assistant Name/Contact (If applicable):
Please describe why you are interested in serving on the NCTNA Board. *
Please provide a brief biography or background information that demonstrates experience and character, if possible. *
PLEASE USE THE FOLLOWING KEY TO RANK APPLICANT SKILL ON CHART BELOW:1= Novice, nominee has never or rarely has encountered a need to develop this skill, doesn’t express great interest in seeking out development opportunities pertaining to this skill 2= Slightly Skilled, nominee has basic and limited experience as it relates to this skill 3= Competent, nominee has been faced with situations that require an understanding of this skill to succeed, nominee may not use this skill every day but feels comfortable with this skill, nominee is interested in continuing to develop this skill 4= Proficient, nominee spends time executing this skill frequently, this skill is used in their life and/or work regularly, nominee is educated and has meaningful experience relating to this skill 5= Expert, this is a nominee’s “bread and butter,” this is the area the nominee EXCELS in, nominee is so adept at this skill that they can and do teach and develop other’s ability as it relates to this skill Please indicate your confidence in the nominee’s familiarity with and ability to utilize the following skills to serve the NCTNA Board: *
PLEASE USE THE FOLLOWING KEY TO RANK APPLICANT SKILL ON CHART BELOW:1= Novice, nominee has never or rarely has encountered a need to develop this skill, doesn’t express great interest in seeking out development opportunities pertaining to this skill
2= Slightly Skilled, nominee has basic and limited experience as it relates to this skill
3= Competent, nominee has been faced with situations that require an understanding of this skill to succeed, nominee may not use this skill every day but feels comfortable with this skill, nominee is interested in continuing to develop this skill
4= Proficient, nominee spends time executing this skill frequently, this skill is used in their life and/or work regularly, nominee is educated and has meaningful experience relating to this skill
5= Expert, this is a nominee’s “bread and butter,” this is the area the nominee EXCELS in, nominee is so adept at this skill that they can and do teach and develop other’s ability as it relates to this skill
PLEASE USE THE FOLLOWING KEY TO RANK APPLICANT AREAS OF INTEREST ON CHART BELOW:
1= Not interested, nominee rarely, if ever, thinks about or expresses interest in this
2= Slightly interested, may spark SOME interest for the nominee, but not enough for them to want to dive further into the subject area
3= Interested, nominee definitely HAS interest in this category, but may not be incredibly familiar with this
4= Very Interested, nominee spends time thinking about or talking about this
5= This is a nominee’s passion, nominee dedicates their personal time to investing in/learning more about/becoming an expert as it relates to this
If you are nominating someone else, have you spoken with the nominee about the position? Have they expressed an interest? * Yes No Unsure
Please provide any other information that would be helpful to the nominating and governance committee.
Nominated By: *
