Neighborhood Recovery Initiative

Advisory Committee Nomination Form

Please return to:

Vickie Rivkin, Project Director
Circle Family HealthCare Network
5002 W. Madison Street
Chicago, IL 60044
(773) 379-1000
(773) 379-1342 fax
or email to vrivkin@cfhcn.org

To nominate yourself or another candidate, please complete this form.

Candidate Information

Full Name:
Last First M.I.
Address:
Street Address Zip Code
Telephone: ( ) Alternate Phone: ( )

E-mail Address:

Employer/Affiliation: Title:_______________

Are you able to attend meetings? (day and evening) Yes___ No ____
Do you live/work in the Austin Community? Yes __ No ___
Why do you want to serve on the Advisory Committee? __________________________________________________

Nominator Information

Full Name: _____________________________________________________________________________________

Affiliation: _____________________________________________________Title:_____________________________

Address:_____________________________________________City_______________State_______Zip__________

Telephone: ______________________________________________ E-mail Address:_________________________

Affliliation:______________________________________________________________________________________

Qualifications
Please describe the nominee’s qualifications, experience, and other reasons why he or
she would be an effective committee member.