Nomination Form - North Carolina STHL - Centralina Area Agency on Aging

Nomination for:

Delegate
Alternate

Name of Nominee

Address

Street Address City State ZIP Code

County of Residence

Date of Birth

Home Phone

Home E-mail

If Currently Employed, Name of Employer

Work Title

Work Phone

Work E-mail

Electronic Signature

Date

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

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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Nomination Form – North Carolina STHL

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