Become a Senior Tar Heel Legislator

North Carolina STHL Nomination Form

Centralina Area Agency on Aging supports the Senior Tar Heel Legislator (STHL) volunteers for our nine-county region. If you are interested in serving as a STHL complete the form below. One of our staff will be in touch to discuss the role further.
General Information
Nomination for:
- Delegate
- Alternate
Name of Nominee*
Address*
Street Address City State ZIP Code
County of Residence*
Date of Birth*
MM slash DD slash YYYY
Home Phone
Home E-mail*
If Currently Employed, Name of Employer
Work Title
Work Phone
Work E-mail
Electronic Signature*
Date*
MM slash DD slash YYYY
Highest Level of Education
- High School - GED
- Associates
- Bachelors
- Masters
- Post - Graduate
If not a self-nomination, please indicate the name, address and phone number of the person or group making the nomination.
Name
First Last
Address
Street Address City State ZIP Code
Phone Number
Question:
Meetings are held during the day. Will this create any conflicts
- Yes
- No
Why do you want to serve on the NCSTHL? If nominating someone else, why do you feel they should serve?*
Describe nominee's experience, background, and knowledge relative to issues important to older adults in North Carolina:*
Describe the nominee's participation in groups or organizations for older adults and in councils or committees that advise or oversee programs that have an impact on older persons:
Describe any special akills or attributes of the nominee that would enhance his/her effectiveness as a delegate/alternate to the North Caronlina Senior Tar Heel Legislature:*
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Become a Senior Tar Heel Legislator

North Carolina STHL Nomination Form

General Information

Question: