This form is to be completed by the Nominee.

Note: You will be asked to upload a professional headshot (JPG/JPEG format) and a short bio of 250 words or less at the end of this form.

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. You will have the ability to leave and return to this form in order to make edits and complete the questionnaire, if necessary. However, you must use the same device (computer) and web browser used to start the survey.

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

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

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* 1. Nominated For

Nominated By

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* 2. Nominated By

Date of Nomination

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* 4. Date of Nomination

Date
Nominee First Name

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* 5. Nominee First Name

Nominee Middle Initial

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* 6. Nominee Middle Initial

Nominee Last Name

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* 7. Nominee Last Name

Home Address/Phone

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* 9. Home Address/Phone

Cell Phone

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* 10. Cell Phone

Gender

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* 11. Gender

Age

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* 12. Age

Date of Birth

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

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

If Native American, what tribe/nationality?**

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

If Pacific Islander, what ethnicity/nationality?**

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

Do you have a disability?

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* 19. Do you have a disability?

Disability Type (if applicable)

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* 20. Disability Type (if applicable)

LGBT

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* 21. LGBT

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

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

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

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

Local Church

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* 24. Local Church

Church Address

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* 25. Church Address

Church City

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* 26. Church City

Church Zip Code

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* 28. Church Zip Code

Church Phone Number

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* 29. Church Phone Number

Number of Members in Local Church (Approx)

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

Type of Local Church

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* 31. Type of Local Church

Year graduated from High School

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* 32. Year graduated from High School

Highest Level of Education Achieved

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* 33. Highest Level of Education Achieved

Field of Study

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* 34. Field of Study

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

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

Nominee – Employment History

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* 36. Nominee – Employment History

Management/Supervisory Positions Held

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* 37. Management/Supervisory Positions Held

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

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

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

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

Hobbies and Recreational Interests

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* 40. Hobbies and Recreational Interests

Biography: Local Church leadership or volunteer positions

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* 41. Biography: Local Church leadership or volunteer positions

Biography: Conference and/or Association leadership or volunteer positions

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

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

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

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

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

Biography: National UCC leadership or volunteer positions

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* 45. Biography: National UCC leadership or volunteer positions

Biography: Ecumenical/Interfaith leadership or volunteer positions

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

Biography: Community/Volunteer positions

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* 47. Biography: Community/Volunteer positions

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

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

Special skills and interests

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* 49. Special skills and interests

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

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

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

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

Two References Required
Name #1

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* 52. Name #1

Contact Information #1 (phone and email)

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

Type of Reference #1

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* 54. Type of Reference #1

Name #2

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* 55. Name #2

Contact Information #2 (phone and email)

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

Type of Reference #2

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* 57. Type of Reference #2

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

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

Please upload a brief bio with no more than 250 words maximum.

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* 59. Please upload a brief bio with no more than 250 words maximum.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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Please upload a professional head shot (JPEG/JPG format preferably). Hi resolution, if possible.

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* 60. Please upload a professional head shot (JPEG/JPG format preferably). Hi resolution, if possible.

JPEG, JPG file types only.
Choose File
No file chosen

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