BOARD NOMINATION
LIFE Center for Independent Living

Date: ____________________

Name: ___________________________________________________________

Address: _________________________________________________________

City, State, Zip: ___________________________________________________

Telephone: (     ) __________    (Circle or highlight one)     Voice     TTY     FAX

E-Mail: __________________________________________________________


Knowledge, skills, and contacts this candidate can offer to the Board: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

Preferred format for print materials: (Please check one)

____ Regular print
____ Large print
____ Braille
____ Diskette
____ Audiotape
____ E-mail

Preferred method of receiving mail:  (Please check one)

____ Mail
____ E-Mail

Please e-mail this page to board@lifecil.org or mail or deliver it to:

President, Board of Directors
LIFE Center for Independent Living
2201 Eastland Drive, Suite 1
Bloomington, IL 61704