Oklahoma Academy 2007 Town Hall

Nomination for Invitation Consideration

“Oklahoma’s Second Century: Building Bridges and Alliances With
Tribal Governments, State & Local Governments and the Private Sector”
October 28 – 31, 2007
(Sunday evening through Wednesday noon)
Quartz Mountain Resort, Lone Wolf, OK
This form may be duplicated if you know of other nominees. In order for nominations to be considered ALL
sections must be completed. Please print or type. Return this form via fax or mail by _________________.

Name: Title:

Business/Organization Name:

Mailing Address:

City: Zip: County:

Email Address: Phone: ( ) Fax: ( )

Academy Member: YES NO

Please circle your age group:

21 --- 24 25 --- 34 35 --- 44 45 --- 54
55 --- 59 60 --- 64 65+

Please answer the following:

Are you Spanish/Hispanic/Latino? No Yes, Mexican, Mexican Am., Chicano Yes, Puerto Rican

Yes, Cuban Yes, other Spanish/Hispanic/Latino: Please print group

What is your race?

White Black, African Am., or Negro American

Indian or Alaska Native: Please print tribe Asian Indian Japanese

Native Hawaiian Chinese Korean Guamanian or Chamorro

Filipino Vietnamese Samoan Other Asian: Please print

Other Pacific Islander: Please print Other race, please specify

~over~
In the space below, please type or print WHY you should be considered as a Town Hall participant.

I would be an excellent participant in this Town Hall because:

I have particular expertise in the following areas: (please circle all that apply)

Health Education &Workforce Infrastructure Economic Development Tourism

Nominated by:

Please return to:

The Oklahoma Academy
120 E. Sheridan, Ste. 200
Oklahoma City, OK 73104
Phone: (405) 232-5828
Fax: (405 236-5268
www.okacademy.org