Idaho Bulletin 230-6-5
Attachment

NOMINATION FOR MEMBERSHIP

NATIONAL CIVIL RIGHTS COMMITTEE

Name: ____________________________________________

Title: ______________________________________________

Grade: _____________________________________________

Work Address: ______________________________________

___________________________________________________

Position Applying for: _________________________________

Work Phone: ________________________________________

VoiceCom: _________________________________________

E-Mail Address: _____________________________________

Please use the back of the form if necessary:

Work Experience (brief description): Include any accomplishments in the Civil Rights area.

Comments: Include reason why you would like to serve on the NCRC.

Statement of Concurrence: (State Conservationist or Director)

_____________________________________________
Signature of Supervisor                                      Date

_____________________________________________
Signature of STC/RC/DC                                    Date

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