Standard Advisory Committee (SAC) Nomination Form

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

Tentative meeting dates for the SAC have been posted on the Nomination Notice.  Please verify that you will be able to attend on these dates prior to submitting this nomination form.  SAC members may be able to 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, May 16, 2014.  If you have any questions or your contact information changes in the future, please contact the CON Policy Section at 517-335-6708.

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 and can attend.
• 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.