Diversity Leadership Development Program Nomination Form

I'd like to nominate the following candidate for the SLA Diversity Leadership Development Program to increase the involvement of diverse members within the Association. (Individuals may nominate themselves.)

___________________________________________________
Candidate's Name

___________________________________________________
Candidate's Address

___________________________________________________
City                                  State                                Zip

Daytime Telephone: (____) _________________

Fax: (____) ______________________

E-Mail: ____________________________________

___________________________________________________
Nominated by (print name and title)

___________________________________________________
Organization

___________________________________________________
Address

___________________________________________________
City                                  State                          Zip

Daytime Telephone: (____) _________________

Fax: (____) _________________

E-Mail: ____________________________________

___________________________________________________
Signature of nominating person

Please return this form with the Candidate's Statement of Interest and List of Professional Experience by 9 January 2008.

Diversity Leadership Development Program
CANDIDATE'S STATEMENT OF INTEREST

Instructions:

The Diversity Leadership Development Program applicant's responses to each section should be typewritten or written in black ink.

This form must accompany the Diversity Leadership Development Program Nomination Form and be submitted no later than 9 January 2008 to:

Linda Broussard, DLDP Staff Committee
SLA
331 South Patrick Street
Alexandria, VA 22314-3501
Fax: +1.703.647.4901
lbroussard@sla.org 

All candidates will be notified by February 2008.

I. PERSONAL DATA (Please type or print in black ink)

___________________________________________________
Name

Male [ ]     Female [ ]

___________________________________________________
Address

___________________________________________________
City                                  State                                Zip

Daytime Telephone: (____) _________________

Fax: (____) _________________

E-Mail: ____________________________________

II. EDUCATION

A. List all colleges/universities attended:

Name of School #1 ____________________________________________

Location ___________________________________________________

Dates Enrolled ______________________

Degree ___________________________________________________

Name of School #2 ____________________________________________

Location ___________________________________________________

Dates Enrolled ______________________

Degree ___________________________________________________

Name of School #3 ____________________________________________

Location ___________________________________________________

Dates Enrolled ______________________

Degree ___________________________________________________

Name of School #4 ____________________________________________

Location ___________________________________________________

Dates Enrolled ______________________

Degree ___________________________________________________

Name of School #5 ____________________________________________

Location ___________________________________________________

Dates Enrolled ______________________

Degree ___________________________________________________

B. Special Awards/Honors (optional):

___________________________________________________

___________________________________________________

III. To which of the following group(s) does the candidate belong:

Racial Diversity:

[ ] Black (African-American, African, Caribbean, West Indian)
[ ] Asian (East, South, Southeast, West, or Arab)/Pacific Islander
[ ] Hispanic
[ ] American Indian/Alaskan Native

[ ] Cultural Diversity (please define): ___________________________

[ ] Sexual Orientation (Gay or Lesbian)

[ ] Nationality or Ethnic Diversity (please specify): _________________

[ ] Religious Diversity (please specify) : ____________________________

[ ] Physical Abilities (please define): ______________________________

[ ] Other: (Please define): __________________________________

IV. STATEMENT OF INTEREST

Please explain why you are interested in this program and what you hope to gain from it. (One page in length maximum, attached.)

V. PROFESSIONAL EXPERIENCE

Please list all employment, volunteer, and other professional projects that may be applicable.
(One page in length maximum, attached.)

VI. PROGRAM REQUIREMENTS

I have read the Diversity Leadership Development Program Outline
and understand the requirements and benefits.

Yes [ ] No [ ]

Signature of Candidate: _______________________________________