NOMINATION FORM FOR KSBA BOARD OF DIRECTORS (REGIONAL CHAIRPERSON) THREE-YEAR TERM

To be considered for election, the nomination form must be completed and received by your Regional Secretary’s office (host district superintendent)
no later than 15 business days before the regional meeting.
Your Regional Secretary’s name, contact information and
Regional Meeting date is included in the attached cover letter.

NAME:   	
(FIRST)	(M.I.)	(LAST)

ADDRESS:   	
(MAILING ADDRESS)

(CITY)	(STATE)	(ZIP)

BUSINESS:

_________________	RESIDENCE:

 	___________	Cell: _________________

(AREA CODE)  (NUMBER)	(AREA CODE)  (NUMBER)	(AREA CODE)  (NUMBER)

E-MAIL:		FAX:   	
(AREA CODE)  (NUMBER)

Please complete all appropriate sections for consideration by regional nominating committees.

PRIMARY OCCUPATION:   	

EDUCATION BACKGROUND:   	

PROFESSIONAL EXPERIENCE:   	

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LOCAL LEADERSHIP EXPERIENCE
(Use separate sheets if necessary):

Name of School District/Board of Education on which you serve: 	

Name of KSBA Region in which you serve: 	

Dates of service on your local school board (including current term):   	

When does your current term expire?   	
(MONTH)	(YEAR)

List all dates and offices that you have held on your local school board:

Position on Local School Board	Dates
(i.e. Member, President, Vice President, Committee Chair, etc.)

Local leadership experience in your community (list community service such as church officer, government experience, Chamber of Commerce, youth organizations, etc.):

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