NCLR Midwest Regional Office NOMINATION FORM TO THE AFFILIATE COUNCIL Spring 2006 Please email jocampo@nclr.org or fax nomination form to the Midwest regional office at (312) 2699260 by May 22, 2006. Nominations will not be accepted after this date. Name of Nominee (if self):____________________________________________________ Affiliate: __________________________________________________________________ City/State: _________________________________________________________________ Phone: _______________________________ Fax: ________________________________ Email: ____________________________________________________________________
Name of Nominee (if other than self): ___________________________________________ Title: _____________________________________________________________________ Affiliate: __________________________________________________________________ City/State: _________________________________________________________________ Phone: ________________________________Fax: ________________________________ Email: ____________________________________________________________________ I certify that the nominee is an employee of an Affiliate organization of the Midwest region of the National Council of La Raza. Signature: ___________________________ Date: _____________________ Email jocampo@nclr.org or fax to (312) 2699260 by May 22, 2006.