National Child Passenger Safety Board Supervisor Approval Form

User Manual: Supervisor-Approval-Form

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National Child Passenger Safety Board
2013 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 technician to be a member of the Board.
At this time the National Child Passenger Safety Board is seeking applicants for the following positions: At Large (1),
Diversity (1), Injury Prevention/Health Care (1) and Public Safety Fire/EMS (1). Selected applicants will begin their
Board service with the first Board meeting of 2014 (January 14-16, tentatively scheduled for Tampa, FL).
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. Additional copies of this 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 p.m. PDT, June 21, 2013. Applications will be
reviewed and candidates will be notified by October 31, 2013.
If you have questions or need additional information, contact: Amy Heinzen, Program Manager, National Safety
Council, Email: amy.heinzen@nsc.org.

NCPSB 2013 Membership Candidate Application
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Title                           : National Child Passenger Safety Board
Author                          : Tony Randall
Creator                         : Microsoft® Word 2010
Create Date                     : 2013:03:25 16:12:17-05:00
Modify Date                     : 2013:03:25 16:12:17-05:00
Producer                        : Microsoft® Word 2010
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