Please print all entries.          

Date Completed /  Signed:__________________________________


I nominate (name) __________________________________________to serve 
on the RCCB SC as a representative of (County or City of Pittsburgh) 
_______________ for the 1999-2000 term. If I am not (or this nominee 
is not) selected for this position, I nominate myself (this person) 
to serve as one of the three at-large SC members.

Nomination submitted by (can be same as above):
Name:_______________________________________________________________
Address:____________________________________________________________
Organization(-s):___________________________________________________
Phone:_______________ Fax:________________ Email:___________________

Information on SC Nominee:
Name:_______________________________________________________________
Address:____________________________________________________________
Organization(-s):___________________________________________________
Phone:_______________ Fax:________________ Email:___________________

Nominees for the RCCB SC must have been a resident of the 
city / county she / he seeks to represent and / or have carried out
community building (community organizing, coalition building, 
promoting human relations and diversity and other activities that 
seek to build a sense of and strengthen communities) for at least 
one year in this city / county.

The Nominee has been a resident of ______________________ 
(city / county nominee will represent) for at least one year 
and / or has been doing community building work in this 
city / county for more than one year. The nominee's community 
building activities include the following (please give specific 
examples of community building activities and accomplishments). 
Please use only the space provided here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________

I commit to serving on the RCCB SC for the 1999-2000 term:


_________________________________________________________/_____/_______
(Print Name here and sign and date above the line:     Date)

Return to Conference Homepage.