Name:

Home Address:

Duty Location/Address:

Job Title:                                                                             Organization:

Home Phone:                                    Work Phone:Same

Membership Category (please circle one):          Active              Retired          Associate

Full Associate         Corporate        Associate Corporate                      Honorary

NBCFAE Region:                                                        NBCFAE Chapter:

Previous positions held in NBCFAE:

Vacant NBCFAE position Nomination/Acceptance Form is for:

Qualifications, knowledge and skills you have that are pertinent to this position: (Please include dates of

specialized experience,  range of knowledge, and other characteristics that makes you  the best

candidate for this vacant office)

Basic eligibility for candidacy will be determined from this form by the NBCFAE Region Membership

Committee. Candidate Nomination/Acceptance Form must be complete, information up-to-date,

signed and postmarked by the due date.  This form is accepted by E-mail and mail only.

Signature:

Date:

Do not write below, to be used for Region Membership purposes.

Date Candidate Nomination/Acceptance Form received in the mail:

Complete/Incomplete              Postmarked by due date/Not postmarked by due date

Signed/Not signed                   Date candidate notified: