This application is for consideration of : *

Name: *

First Last

Current Title: *

Expiration Date of Term:

MM / DD / YYYY

Answer if in an elected office.

If your term expires prior to January 1, 2018, do you plan to run again?

Yes

No

All applicants must be active through December 31, 2018 to be considered for appointment.

Preferred Email: *

Primary means of communicating with NLC.

Confirm email:

Preferred Phone: *

### - ### - ####

Daytime phone number

Cell Phone:

### - ### - ####

If your preferred daytime phone number is not your cell phone.

Alternate Email:

If you wish to use a personal or other email to receive communications from NLC. (e.g., your Administrative Assistant)

City or Town: *

State: *

Your Municipality's Setting: *

Your City's Population: *

Do you have an endorsement from your State Municipal League? *

Yes, I have received an SML endorsement

No, but I will likely receive an SML endorsement

No,

The endorsement is not required, but strongly encouraged.

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