Diversity Leadership Development Program
Nomination Form
Diversity Leadership Development Program Award Outline
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 by email to pdiaz@sla.org with the Candidate's Statement of Interest and List of Professional Experience by April 11, 2012.
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. All applications must be sent by email to pdiaz@sla.org no later than April 11, 2012.
All candidates will be notified by the end of April 2012.
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: _______________________________________
RSS
Feedback form
