With the submission of this form, the Nominee consents to a criminal background check, for the purposes of compliance with the Safe Church Policy, to be conducted prior to final selection by the Nominating Committee and presentation of the Nominee to the General Synod for election.

With the submission of this form, the Nominee consents to having their name placed before the General Synod for election.

With the submission of this form, the Nominee acknowledges an understanding that they will be approached for a financial contribution to the United Church of Christ above their current level of giving.

While the Report of the Nominating Committee will likely be released in late winter 2018 or early spring 2019, Nominees are advised the Report of the Nominating Committee (The Slate) is not required for public release until 24 hours prior to the election by Synod. Nominees and nominating bodies are advised to not inquire into the status of nominations. All nominees will be informed of the selections by the Nominating Committee prior to release of its Report.

All information is to be captured and completed by the Nominee.

To review the expectations of the UCC Board Members, click here.

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* = Required Field. If a field is required and the information is currently unknown to you, please note as NA.

* 1. Nominated For

* 2. Nominated By

* 4. Date of Nomination

Date

* 5. Nominee First Name

* 6. Nominee Middle Initial

* 7. Nominee Last Name

* 9. Home Address/Phone

* 10. Cell Phone

* 11. Gender

* 12. Age

* 13. Date of Birth

Birth Date
**This optional information was requested by the Pacific Island and Asian American Ministries and the Council for American Indian Ministries.

* 16. If Asian/Asian American, what ethnicity/nationality?**

* 17. If Native American, what tribe/nationality?**

* 18. If Pacific Islander, what ethnicity/nationality?**

* 19. Do you have a disability?

* 20. Disability Type (if applicable)

* 21. LGBT

* 22. Do you belong to one of the organized Historically Underrepresented Groups (HUGS) recognized by the UCC?

* 23. If you belong to a Historically Underrepresented Group, to which of the groups do you belong?

* 24. Local Church

* 25. Church Address

* 26. Church City

* 28. Church Zip Code

* 29. Church Phone Number

* 30. Number of Members in Local Church (Approx)

* 31. Type of Local Church

* 32. Year graduated from High School

* 33. Highest Level of Education Achieved

* 34. Field of Study

* 35. Current Occupation
(If retired, please note “retired from _______”.)

* 36. Nominee – Employment History

* 37. Management/Supervisory Positions Held

* 38. Employment skills that will be brought to the United Church of Christ Board of Directors

* 39. Life Experiences that will be brought to the United Church of Christ Board of Directors

* 40. Hobbies and Recreational Interests

* 41. Biography: Local Church leadership or volunteer positions

* 42. Biography: Conference and/or Association leadership or volunteer positions

* 43. Have you previously served on a national board of the United Church of Christ?

* 44. If you previously served on a national board of the United Church of Christ, which board?

* 45. Biography: National UCC leadership or volunteer positions

* 46. Biography: Ecumenical/Interfaith leadership or volunteer positions

* 47. Biography: Community/Volunteer positions

* 48. Do you serve on the Board of Directors for any other organization?

* 49. Special skills and interests

* 50. Please use this space to share additional information related to your selected skills and interests.

* 51. Please share briefly why you would like to serve on the United Church of Christ Board of Directors.

Two References Required

* 52. Name #1

* 53. Contact Information #1 (phone and email)

* 54. Type of Reference #1

* 55. Name #2

* 56. Contact Information #2 (phone and email)

* 57. Type of Reference #2

* 58. Typing your name to complete this form constitutes your electronic signature.

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