NOMINATION FORM

I. NOMINEE’S PERSONAL DATA
Name*
First Middle Last
Street Adress*
Apartment Unit*
City*
State
ZIP Code*
Phone*
Email*
Date of birth*
Date Format: DD slash MM slash YYYY
Occupation*
Employer
Education
2. Luso-American Financial membership information
Number of years as member of Luso-American*
Branch*
- LUSO
- SPRSI
Local Council Name/number*
City and State of Council*
Positions Held*
Local officer submitting nomination
Position
Street Adress*
City*
State*
ZIP Code*
Phone*
Email*
3. STATEMENTS
Please review the following three categories and provide your responses in the space provided.
A. FRATERNAL SUPPORT*
B. COMMUNITY SERVICE*
C. ACHIEVEMENTS, ACCOMPLISHMENTS & AWARDS*
E. ADDITIONAL INFORMATION*
Council Officer’s Printed Name*
Position*
Council Officer’s Signature*
Upload Signed Document
Date*
Date Format: DD slash MM slash YYYY
Attachment of any supporting documentation*
Attachment of any supporting documentation
Consent*
I agree to the Terms of Service & Privacy Policy*

I. NOMINEE’S PERSONAL DATA