Name of Applicant:

E-Mail Address of Applicant:

* Required

Campus Location:

University Address:

University Phone:

Position / Title:

Position Description:

Faculty
Administrator
Staff
Technical-Service

Name of Immediate Supervisor:

Supervisor's Address:

Immediate Supervisor’s Supervisor Name: (Important)

Immediate Supervisor’s Supervisor Address: (Important)

Please Indicate Membership Type

Commission work can involve a substantial time commitment (upwards of several hours per month). You may apply for full or affiliate membership; however, if your time constraints are more limited, you may want to consider applying for affiliate membership. Full members are expected to attend all commission meetings and participate on commission subcommittees, whereas affiliate members may attend more periodically and subcommittee participation is voluntary. Only full members have voting rights. Affiliate membership is for one year, which can be renewed annually; full membership is a three- to four-year appointment, depending on the specific commission. Affiliate members may apply for full membership status the following year.

Type of Membership desired:

Full Membership
Affiliate Membership

Yes
No
N/A

On a monthly basis, how many hours would you generally be able to commit to commission work?

2-4 hours
4-6 hours
6-8 hours
More than 8 hours

Please Indicate Commission Selection

If someone else nominated you, it is possible, if you prefer, to choose a different commission from the one indicated in your nomination.

Please select the commission you would most like to serve on:

Commission on Lesbian, Gay, Bisexual and Transgender Equity
Commission on Racial/Ethic Diversity
Commission for Women

If the application pool is full for your first selection, please indicate if you would like to be considered for any other commission:

Second Choice:

Third Choice:

Please indicate the name of the person nominating you (if self-nomination, please indicate so by writing “self” in the Name of Nominator space):

Name of Nominator:

* Required

E-Mail Address of Nominator:

* Required

Have you previously served on one of the commissions?

Yes
No

If yes, which commission and term(s) (approximate if necessary):

Which Commission(s):

Term(s)

Do you have special skills, talents, expertise, or areas of interest that may benefit committee assignments? (e.g., employee concerns, student issues, marketing, information technology, athletics, and curriculum):

Please indicate contributions that you have made towards enhancing equal opportunity and diversity: (e.g., committee service, research, publications, and presentations).

Upon submitting this nomination, you will receive email confirmation. Copies of this nomination will be forwarded to the Office of the Vice Provost for Educational Equity and the relevant commission.