First Name: 

Last Name: 

Mailing Address:

Position Title:  

Library Name: 

City: 

Zip Code: 

Type of library:
Academic PublicSchool Media Special Other

Telephone: 

E-mail: 

Experience, Skills, and Activities

Professional Experience: (list current position followed by previous two)

Special Skills:

Professional Associations: (memberships other than FLA)

Other Activities Relevant to Committee Member Work:

Number of Years as an FLA Member: 

Are you interested in being a Committee Chair or Vice-Chair? Yes No

Committee Choices: