Name of nominee * Name of Organization (must be a community health center) * Position sought (check all that apply): *
Chair (two-year term)
Co-Chair (two-year term)
Member At-Large (two-year term)
Member At-Large (one-year term)
Regional Representative, Regions 1&2 (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Massachusetts, New York, New Jersey)
Regional Representative, Regions 6&8 (Arkansas, Louisiana, Texas, Oklahoma, New Mexico, Colorado, Utah, Wyoming, Montana, South Dakota, North Dakota)
Regional Representative, Regions 5&7 (Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, Nebraska, Kansas)
Please note that Steering Committee Members are expected to make at least 75% of all monthly NCAB calls held at 5pm ET on the third Wednesday of each month; Nominees should expect to devote two hours each week towards NCAB activities.
I am someone who (check all that apply): *
Join NCAB and the National Health Care for the Homeless Council for free at www.nhchc.org/about/membership/individual-members/.
Address (nominee address if applicable)
* Phone (nominee number if applicable) * Email (nominee email if applicable) *
If the nominee does not have an email address, please seek help in the community to sign up for one or contact Katherine Cavanaugh at email@example.com. Having an email address is a requirement of an NCAB leadership position as most communication happens through email.
Statement by Nominee *
Please describe in 300 words or less your experience as a consumer, your involvement with agency decision making or governance, and the contribution you feel you could make to the work of the National Consumer Advisory Board.
Please note: You may provide additional letters of support or references to provide the nominating committee with additional information to support your nomination and to enhance the committee's understanding of your potential contributions, those letters can be sent to Katherine Cavanaugh at firstname.lastname@example.org. NCAB will also contact you for an informal interview.
Nominator name (if different from nominee)
Position/Title Organization Address
Statement by nominator
Tell us why you believe the above-named nominee would make a valuable addition to the NCAB leadership team.