As part of your submission, a letter of designation from the represented organization must be included with your resume/summary file attached to this form.  The letter must authorize you to represent the organization in the capacity selected below.

Tentative meeting dates for the SACs have been posted on the Meetings Page.  Please verify that you will be able to attend on these dates prior to completing this nomination form, as no alternates are being allowed.  SAC members may participate via a conference call provided that a physical quorum is present at all meetings. 

All requested information, including attaching a file containing a summary/resume and the letter from the represented organization, must be completed for this submission to be valid.  All nomination forms must be submitted by 5:00 p.m. on Friday, April 24, 2009.  If you have any questions or your contact information changes in the future, please contact the CON Policy Section at 517-335-6708.

Name:

Organization Represented:

Please consider my nomination for:
-Bone Marrow Transplantation (BMT)

Select all applicable member capacities pursuant to MCL 333.22215(1)(l):
-Representative of an organization concerned with health care consumers
-Expert (As defined in the Commission Resolution.)
-Representative of a payer of health care services
-Representative of a health care provider organization concerned with licensed health facilities or licensed health professionals
-Representative of a purchaser of health care services

Please note additional selection criteria.

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 the one (1) to two (2) page summary/resume of your expertise in the subject matter and a 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.

Michigan law states under Public Act 619 of 2002 (as an act to amend 1978 PA 368), Section 22215 (1)(l) that the "composition of a standard advisory committee shall not include a lobbyist registered under 1978 PA 472, MCL 4.411 to 4.431."

With submission of this form, I certify the following:

• That I am requesting appointment to a SAC of the Certificate of Need Commission.
• That I am authorized to represent the organization identified in the capacity selected.
• That I am currently employed as listed above.
• That I make this disclosure in that official capacity.
• That I have reviewed the tentative meeting dates.
• That I am not a registered lobbyist in the State of Michigan as defined under 1978 P.A. 472, MCL 4.411 to 4.431.
• That I have not served on two (2) SACs in the previous two (2) years from today's date.

I declare that all information and statements are true to the best of my knowledge and belief.