MACA Board Nomination Form
Board Position to be nominated for:
Date:
Nominee's Name:
Nominee's Address:
Nominee's Duty Position:
Nominee's Phone Number:
Nominee's Supervisor's Name:
Nominee's Agency Address (Include State and Zip code) 
Supervisor's Title:
ACFA License #:
Has the nominee ever been convicted of an animal law violation or felony of any sort?
If yes, explain:
Is the Nominee willing and able to commit to attending board meetings as necessary to conduct the Association’s business, and to attend MACA Training Venues?
Nominee's Email Address:
# of years as a MACA Member:
Length of time the nominees has worked in an animal welfare position: 
Nominee's Agency:
Supervisor's Agency Address :
Supervisor's Phone Number:
Supervisor's email address:
In the space below, please explain the nominee’s educational background, experience, qualifications and any other information stating why he or she would be a good candidate for an Executive Board position. 
YesNo
YesNo