http://www.ncagr.gov/SWC/districts/forms.html Version 05.17.16
DIVISION OF SOIL AND WATER CONSERVATION
North Carolina Department of Agriculture & Consumer Services
1614 Mail Service Center • Raleigh, NC 27699-1614
919.707.3770 • www.ncagr.gov/swc/
RECOMMENDATION FOR APPOINTMENT OF SUPERVISOR
Complete and submit online on your district’s SharePoint page; keep original for your file
The supervisors of the ______________________________ Soil and Water Conservation District of ___________________
County, North Carolina have recommended the individual listed below for APPOINTMENT as a district supervisor
in accordance with N.C.G.S. 139-7 for a term of office commencing _______________ and ending ______________
to fill the expired or un-expired term of ___________________________________.
Name of nominee: _________________________________________________________________________________
A
ddress of nominee, City, State, Zip: ________________________________________________________________
Email address of nominee: __________________________________________________________________________
Home phone: ______________________________________________________________________________________
Mobile phone: _____________________________________________________________________________________
Business phone: ____________________________________________________________________________________
Occupation: ______________________________________________________________________________________
Age: ______________________________________________________________________________________________
Education: ________________________________________________________________________________________
Positions of leadership NOW held by nominee: _______________________________________________________
Former occupations or positions of leadership contributing to nominee’s qualifications: ________________
___________________________________________________________________________________________________
Other pertinent information: ________________________________________________________________________
___________________________________________________________________________________________________
Dates of previous attendance at UNC School of Government training, if applicable: __________________
Is nominee willing to attend a training session at the UNC School of Government within the first year after
appointment? Check for “Yes”
Has the nominee been contacted to determine their willingness to serve? Check for “Yes”
Has the program and purpose of the soil and water conservation district been explained to the nominee?
Check for “Yes”
Is the nominee willing to attend and participate in local district meetings? Check for “Yes”
Is the nominee willing to attend and participate in Area meetings? Check for “Yes”
Is the nominee willing to attend and participate in State meetings? Check for “Yes”
Signatures
I hereby certify that the board of supervisors considered the Guiding Principles for Supervisor Nomination for Appointment shown on the
reverse of this nomination form when selecting the above supervisor candidate for nomination. I also certify that this recommendation has
been considered and approved by a majority of the members of the board of supervisors and entered in the official minutes of the board.
X
SWCD Chair (or Vice Chair if Chair is being nominated) Date
Printed name:
I
hereby certify that the above information is true and accurate.
X
Indi
vidual recommended for appointment Date
Printed name:
INTERNALUSEONLY:
Appointed/Elected Seat
CurrentTerm:
