APPLICATION FOR OSIA BOARD NOMINATION & COMMITTEE APPOINTMENT
Name________________________________________ Date___________________
Title___________________________________ E-mail________________________
Organization or Company_______________________________________________
Address______________________________________________________________
Phone ________________________ Fax__________________________________
ELECTED
POSITIONS
President ______ Vice President ______
Secretary/Treasurer ______
Associate Member Representative Director ______
Regular Member Representative Director ______
APPOINTED
POSITIONS
Committee Chair Positions (check any committee or committees you
would like to serve on as chair):
Membership ___
Program ___ Legislative
___ Finance/Budget ___
Communications ___ Integrated Benefits ___ Loss Control ___
COMMITTEE
POSITIONS
Check any committee or committees you would like
to serve on:
Membership ___
Program ___ Legislative
___ Finance/Budget ___
Communications ___ Integrated Benefits ___ Loss Control ___
Signature
of Applicant ______________________________________________
Please return by March 12: OSIA, 114 Coolidge
St., Silverton, OR 97381
Or fax to 503-873-9389