2014 Supervisor Approval Form

User Manual: 2014-Supervisor-Approval-Form

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National Passenger Safety Board
2014 Membership Application - Supervisor Approval Form
The National Child Passenger Safety Board is a collaborative voice providing guidance for the safe transportation of
children and ensuring the integrity of the child passenger safety training and certification program. The Board consists of
up to 22 members — 10 who are appointed by their organization and 11 to 12 who are selected through the open
application process. It is not necessary to be a certified child passenger safety technician to be a member of the Board.
At this time the National Child Passenger Safety Board is seeking applicants for the following positions: CPS
Advocate (1), Injury Prevention – Public Health (1), and Public Safety – Law Enforcement (1). Selected applicants
will begin their Board service with the first Board meeting of 2015 (January 2015, tentatively scheduled for Charlotte,
NC).
Name: _________________________________________________________________________________________
Job title: ________________________________________________________________________________________
Organization/Agency: _____________________________________________________________________________
Work Address: ___________________________________________________________________________________
Work Phone: (

)______________________

Work Fax: (

) _____________________

TO BE COMPLETED BY APPLICANT’S SUPERVISOR or SPONSORING ORGANIZATION’S CEO/EXECUTIVE DIRECTOR or
THE APPLICANT IF APPLYING AS AN INDIVIDUAL.
I understand that Board membership is voluntary, there is no compensation, and members are responsible for their own travel
expenses. I have discussed with the applicant how their time and travel expenses will be compensated should s/he be elected to
the National Child Passenger Safety Board.
________________________________________
Printed Name

________________________________________
Signature

________________________________________
Title

________________________________________
Date

The information provided on this application is complete and accurate:
Printed Name of Applicant: _______________________________________________________
Signature: _____________________________

Date: ______________________________

A complete application consists of the completed online application form and uploaded copies of the supervisor approval
form and a resume. Additional documentation will not be reviewed. Complete instructions for application may be
downloaded from the CPS Board website: www.cpsboard.org.
Original application and applicant resume must be received no later than 5:00 PM PDT, June 13, 2014. Applications will
be reviewed and candidates will be notified by October 31, 2014.
If you have questions or need additional information, contact: Amy Artuso Heinzen, Program Manager, National
Safety Council, Email: Secretariat@cpsboard.org.

NCPSB 2014 Membership Candidate Application
Source Exif Data: 
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.5
Linearized                      : No
Page Count                      : 1
Language                        : en-US
Author                          : Amy Heinzen
Creator                         : Microsoft® Word 2010
Create Date                     : 2014:03:31 11:11:32-05:00
Modify Date                     : 2014:03:31 11:11:32-05:00
Producer                        : Microsoft® Word 2010
EXIF Metadata provided by EXIF.tools

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