As part of your submission, a letter of designation from the represented organization authorizing you to represent the organization in the capacity selected below.  The letter of designation and your resume must be contained in one DOC or PDF file and attached to this form.

All requested information, including attaching a file containing your resume and the letter from the represented organization, must be completed for this submission to be valid.  All nominations must be received prior to 5:00 p.m. on Wednesday, August 27, 2008. If you have any questions or concerns, please feel free to contact the CON Policy Section at 517-335-6708.

Name:

Organization Represented:

Member Capacity (At this time, nominations are being accepted for only healthcare provider organization concerned with licensed health facilities or licensed health professions.):
-Representative of a healthcare provider organization concerned with licensed health facilities or licensed health professions.
     -Persons knowledgeable in medical technology.
     -Representative of a healthcare consumer organization.
     -Representative of a healthcare purchaser.
     -Representative of a third party payer organization.
     -Faculty member of a school of medicine in the State of Michigan.
     -Faculty member of a school of osteopathy in the State of Michigan.
     -Faculty member of a school of nursing in the State of Michigan.

Contact Information:
Business Name:
Position Title:
Years in this Position:

Address:
Address:
City: State: Zip:

Business Phone:
Business Fax:
Cell Phone:

Email:

Please attach a single DOC (Word) or PDF file containing both your resume and the letter of designation from the represented organization.  Note: Both documents must be contained in a single file.  The file name cannot contain a space within it or an error will be received (i.e., SmithResume will be accepted, but Smith Resume will not be accepted and an error will be received).