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Nominee’s Form - General Use


TO BE COMPLETED BY THE NOMINEE
* indicates required data
  Nominated for :*       
Specify which Board or Churchwide Committee
1.* Please provide full, legal name


 

 
* Title * First name Middle name * Last name Suffix

 
NOTE: TO SATISFY ELCA CONSTITUTIONAL REQUIREMENTS ON NOMINATIONS,
THE FOLLOWING SECTION MUST BE COMPLETED.
FAILURE TO DO SO WILL PRECLUDE CONSIDERATION OF NOMINATION.

 
A. *Gender: B. *Birthdate (mm/dd/yyyy): C. *Primary language English:
D. *Ethnic/Racial Group :
E. *Are you :
     If rostered, by which synod:
     If rostered, provide your Rostered Leader Key:
F. *Are you willing to serve, if elected?
G. *Are you related to an ELCA churchwide staff member?
     If yes, print name here.
     If yes, by what relationship:
H. *If you are a nominee for the Board of Pensions (Portico Benefit Services),
     are you a member or potential recipient of benefits in any form of the pension plan?

2.*
Preferred
Mailing
Address

*
Street Address, P.O. Box, c/o, etc.

Apartment number, unit, floor, etc.

* Type

*
City

*
State
-
*
ZIP Code

Country

3.
Residence:
if different from
Preferred
Mailing
Address

Street Address

Apartment number, unit, floor, etc.
 

City

State
-
ZIP Code

Country

4.*
Telephone: (Preferred) *
(Alternate)

5.* E-mail :
             (Confirmation will be sent to the e-mail address above.)

6.*
Are you a member of an ELCA Congregation ?
Congregation name (partial) : State :
Tip: Enter one word from the congregation's name (ex. Paul for St Paul Lutheran Church)
and the state abbreviation before clicking "Search."
Congregation Membership :

7.
Educational Institutions:
a. From to
Degree  
b. from to
Degree
c. from to
Degree

8.
Employer
(current or
most recent)
:

Name

City

State
Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy)
Position/Title (if applicable):
Date retired (if applicable): (mm/dd/yyyy)

9.* List current or past congregational, synodical, or churchwide service activities: (include the year of service)
a.
from to
b. from to
c. from to

10.* In two or three brief paragraphs, describe your sense of God calling you into mission and service in the Evangelical Lutheran Church in America through the work of this board or committee.
What are the gifts, skills, experiences and areas of expertise that you would bring to this work?
(1000 characters max, 1000 characters remaining ...)


11.
If you are not nominated to serve on the board or committee for which you have applied,
would you consider serving on another? If so, which one(s) ?



12.
Please give us the name of someone who can speak to your skills and attributes related to your previous congregational, synodical, or churchwide service activities:
Name:
Phone number:
Email:
What is your relationship to this person?

   Sunday, April 20, 2014 7:10 PM
(if desirable, please print before Submitting)

Contact the Office of the Secretary: 8765 West Higgins Road, Chicago, IL 60631 | 800.638.3522 ext. 2800