To place a name in nomination, print the Nomination Form below, complete it, and send to:

DignityUSA Nominating Committee
1500 Massachusetts Ave NW, Suite 11
Washington, DC 20005-1894
or by Fax at 202-429-9808

Nominations must be submitted no later than April 15, 2004.

Date:

Completed By:

Name:

Street Address:

City:

State :

Zip:

Home Phone:

Work Phone:

 

Fax Number:

DOB (optional)

E-Mail Address:

Current employment/employer (optional):

 

Educational Background:

 

 

Professional Skills or Training:

 

 

Volunteer Experience (including past/present board memberships)

Organization

Activity / Position

Length of Service

     
     
     
     

Comments or Statement — Why do you want to serve on Dignity’s Board of Directors ( to be completed by Nominee).