Nominations Process - Evangelical Lutheran Church in America

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Nomination Form - General Use

TO BE COMPLETED BY 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: IN ORDER 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 : LayClergy
If rostered, by which synod: If rostered, provide your Rostered Leader Key:
F. *Are you willing to serve, if elected? YesNo
G. *Are you related to a ELCA churchwide staff member? YesNo
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? YesNo

2.*

Preferred Mailing Address	* Street Address, P.O. Box, c/o, etc.		Apartment number, unit, floor, etc.	* Type
Preferred Mailing Address	* City	* State	- * ZIP Code	Country

Residence: if different from Preferred Mailing Address	Street Address		Apartment number, unit, floor, etc.
Residence: if different from Preferred Mailing Address	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 ?

YesNo

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 :

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

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?

Saturday, May 25, 2013 6:16 AM
(if desirable, please print before Submitting)

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