2. First Name
3. Last Name
5. Position/Title
7. Business/Organization Representing
9. Please check one:

   1. New Application

   1. Current Member Renewal Application
11. Representation – Complete One Section (1, 2, or 3) relevant to the category that you represent. All applicants must hold optimum policy-making authority or optimum hiring authority.
13. Please check one identifer:

    1. I hold optimum policy-making authority

    1. I hold optimum hiring authority
15. Category 1: Business Representative

    A. Select one of the following Roles that you fulfill:

    1. Business Owner
    2. Business Chief Executive Officer or Chief Operating Officer
    3. Other (Describe policymaking and/or hiring authority)
17. If Other is checked please describe policy making and/or hiring authority.
19. B. Select one of the following Business Types that you represent.

    1. Private Sector Large/For-Profit Business (500 employees or more)
    2. Private Sector Small/For-Profit Business (fewer than 500 employees)
    3. Organization Representing Business
21. C. Describe the In-Demand Industry or Occupation represented by your business.
23. D. Describe Employment Opportunities in the In-Demand Industry or Occupation provided by your business.
25. E. Describe the nature of your business and your position. Please include a description of your policy- making and hiring responsibilities within your organization, including the role you play in training and/or employee development.
27. F. Select Organization Type nominating you.

    1. Local Business Organization (List Org Name)
    2. Business Trade Association* (List Org Name)

    *Association type must be affiliated with the in-demand industry represented by your business.
29. List Organization name, if Local Business Organization is checked.
31. List Organization Name , if Business Trade Association is checked.
33. Category 2: Workforce Representative
35. A. Select one or more of the following Organization Types that you represent.

    1. Labor Organization
    2. Registered Apprenticeship Program (Joint Labor-Management or Union-Affiliated)
    3. Community-Based Organization (CBO) providing services to individuals with barriers to employment
    4. Youth Training, Youth Employment, or Youth Education Organization (WIOA-eligible Youth)
37. B. If you selected Registered Apprenticeship Program, select one of the following roles that you fulfill.

    1. Training Director
    2. Member of a Labor Organization (List Org Name)
39. If Member of Labor Organization is checked, please give the name of the organization.
41. C. If you selected Community-Based Organization above, describe the organization’s demonstrated experience addressing employment, training, and education needs to those with barriers to employment.
43. D. If you selected Youth Training, Youth Employment, or Youth Education Organization for Disconnected Youth, describe the organization’s demonstrated experience addressing employment, training, and education needs to WIOA- eligible youth. State if the experience is serving in-school or out-of-school youth.
45. E. If you selected Labor Organization or Registered Apprenticeship Program above, list the Local Labor Federation nominating you.
47. Category 3: Other Representative
49. A. Select one of the following Organization Types in which you have optimum policy-making authority.

    1. Adult Education and Literacy Provider WIOA Title II
    2. Higher Education (Providing workforce development activities
    3. Economic and Community Development Entity
    4. Wagner-Peyser (Arizona Department of Economic Security) WIOA Title III
    5. Vocational Rehabilitation (Arizona Department of Economic Security) WIOA Title I
51. B. Name of Organization nominating you.
53. Additional Information:
55. Business/Organization Address
57. City
58. State
59. Zip
61. Phone
62. Fax
64. Mobile
66. Email address
68. Website address
70. Business license number
72. 1. The Coconino County Board of Supervisors values member diversity reflecting the demographics of Coconino County. Briefly describe how your appointment would contribute to the diversity of the Workforce Development Board. (Response Optional)
74. 2. Please list your current chamber and association memberships, the duration of each membership and the positions you currently hold.
76. 3. Please list any professional award(s) or recognition you have received within the last 5 years.
78. Coconino County WDB Related Questions
    Please answer the following questions by attaching additional pages:
80. 1. The purpose of the WDB is to provide strategic leadership and operational oversight to Coconino County’s workforce development system through building partnerships, developing career pathways, and providing highquality workforce development services. What knowledge skills and abilities do you have that would assist the WDB in effectively achieving this?
82. 2. Membership on the Coconino County WDB requires that each member attend a full WDB meeting every quarter, attend training sessions for board members and become an advocate for workforce development. The time commitment for these activities ranges from 4 to 6 hours per month. Can you make this time commitment?

    1. Yes
    2. No
84. 3. Serving on a subcommittee of the Coconino County WDB is strongly encouraged. The time commitment for this activity ranges from 3 to 4 hours per month. Can you make this time commitment?

    1. Yes
    2. No
86. 4. Why do you wish to serve on the Coconino County WDB? (Describe in 100 words or less).
88. Additional Required Documentation:
90. ◼ Nomination Letter: Please include a letter from a senior executive of the nominating organization you listed above in your category of representation.
    ◼ Current Resume.
92. Upload Nomination Letter
93. Upload Current Resume
95. Signature and Acknowledgement:
97. I, the undersigned, certify that the information on this application is true and correct to the best of my knowledge and that, if appointed to serve, I will do so to the best of my ability and in the best interest of Coconino County and its citizens.
99. Signature
100. Date
102. To be completed by County official only
104. Date Received By Coconino County
105. Received By
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111. 1. Receive an email copy of this form.
112. Email address

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113. Submit

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