Board Nomination Form
In your nomination, please consider individuals who believe in and support MHAPA’s values and show dedicated professional and/or personal commitment to working for a just, humane, and healthy society that accords all people respect, dignity, choice, and the opportunity to achieve their full potential free from stigma and prejudice.
Please return completed applications, along with the nominee’s current resume or bio, to:
Sue Walther, Executive Director
Mental Health Association in Pennsylvania
1414 North Cameron Street
Harrisburg, PA 17103
By email: y fax: 717-236-0192
Please mark CONFIDENTIAL on the outside of the envelope, fax cover sheet, or in the email subject line. The information on this form is for the sole use of MHAPA’s Board and Nominating Committee and is considered confidential. The deadline for submission is March 8, 2010.
I. Information about nominee
Nominee’s Name:
Title/Occupation:
Organization/Firm:
Address:
City/State/Zip:
Phone: E-Mail:
II. Information about nominator
Nominator Name:
Title/Occupation:
Organization/Firm:
Address:
City/State/Zip:
Phone: E-Mail:
Relationship to MHAPA:
III. Experience and leadership
(Use additional pages if necessary.)
Please list any special attributes of this person that would enhance the diversity of the MHAPA Board (i.e., race/ethnicity, disability, consumer or family member, sexual orientation, age, geographic location, gender, or veteran).
What skills/experience will this candidate bring to the board? And how will this candidate’s involvement on the board strengthen the organization. (Use additional pages if necessary.)
On a scale of 1-5 (with 1 being the lowest and 5 being the highest), please provide your assessment of the candidate’s ability and experience in the following areas:
1. Energy and enthusiasm for MHAPA 12 3 4 5
2. Leadership 1 2 3 4 5
3. Ability to influence legislation 12 3 4 5
4. Ability to raise funds for MHAPA 1 2 3 4 5
5. Officer potential 1 2 3 4 5
Please check those areas in which you believe the candidate excels:
Admin. & Finance Cultural Competence Public Policy
Advocacy Financial Development Public Relations/Image
Communications Legal Matters Strategic Planning
Corporate/Foundation Gifts Public Education Training
Other:
III. Nominee consent
The nominee must have consented to be considered for a position on the board in order to be considered. By signing below, you have indicated the nominee’s consent and clearance for MHAPA to send an application form to the nominee at the address provided above.
I have contacted the nominee and s/he is interested in serving on the MHAPA Board of Directors. Please send him/her an application.
Signature of nominator: ______
Date: ______
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