Company Name:
Name of Nominee:
Number of Employees:
Company Products/Services:

Street Address:
Street Address 2:
Zip Code:
Email Address:
Phone Number:
Briefly state why you are interested in becoming a member of the Workforce Investment Board:

The appointment of business members to the Workforce Investment Board is based upon a variety of elements, including, but not limited to, industry, employer size, current board composition, etc.