BEFORE THE STATE DEPARTMENT OF EDUCATION STATE OF NEBRASKA
In the Matter of the Negotiated) Application/Nomination
Rulemaking Committee for) for membership
[Insert name of the proposed) on the committee
Negotiated Rulemaking Committee],) (interest inadequately
____ NAC ____ .) represented)
APPLICATION FOR MEMBERSHIP
(complete if applicable)
1. The undersigned person (the applicant) hereby applies for membership on the above-referenced negotiated rulemaking committee. ___________________________________
Name of applicant (typed or printed)
__________________________________________________
Full address of applicant
__________________________________
Applicant's telephone number (including area code)
2. The applicant represents the following identifiable interest which will be significantly affected by the proposed administrative rule being considered by the above-referenced negotiating rulemaking committee:3. The applicant is authorized to represent parties related to the interest listed above because:4. The applicant can adequately represent the parties and interest listed above because:5. Reasons that persons already serving on the above-referenced negotiated rule making committee do not adequately represent the interest listed in paragraph 2 above include:6. In support of his or her application, the applicant has attached the following documents to this petition (list all attachments):7. By signing this application, the applicant hereby certifies that he or she will represent the interest identified above to the best of his or her ability in the negotiation process, and that he or she is willing to actively negotiate in good faith to reach a consensus on the proposed rule being considered by the above-referenced negotiated rulemaking committee. _________________________________ Date _____________________
Signature of Applicant
NOMINATION FOR MEMBERSHIP
(complete if applicable)
1. The undersigned person (the nominating party) hereby nominates the following person (the nominee) for membership on the above-referenced negotiated rulemaking committee. __________________________________
Name of nominee (typed or printed)
__________________________________________________
Full address of nominee
___________________________________
Nominee's telephone number (including area code)
2. The nominee represents the following identifiable interest which will be significantly affected by the proposed administrative rule being considered by the above-referenced negotiated rulemaking committee:3. The nominee is authorized to represent parties related to the interest listed above because:4. The nominee can adequately represent the interest listed above because:5. Reasons that persons already serving on the above-referenced negotiated rule making committee do not adequately represent the interest listed in paragraph 2 above include:6. In support of the nomination of the nominee, the nominating party has attached the following documents to this petition (list all attachments):7. The nominating party believes that the nominee will represent the interest identified above to the best of his or her ability and that the nominee is willing to actively negotiate in good faith to reach a consensus on the proposed rule to be considered by the above-referenced negotiated rule making committee because: _____________________________________ Date _________________
Signature of Nominating Party
____________________________________________
Name of nominating party (printed or typed)
_________________________________________________________
Full address of nominating party
______________________________________________
Telephone number of nominating party (include area code)
92 Neb. Admin. Code, ch. 64, Attachment 3