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Firmisconsidered(small)(medium)(large)initsfield.Firmoperationsareprimarily(local)(regional)(national).Membershipinotherrelatedorganizations:򀀀  '% ЀArchitect/EngineerLicenses(show ( ' statesanddatesregistered): )l )  )l ) 򀀀 )l ) College/UniversityEducation:򀀀 F+!+ 񀀀 ,0#-   ,0#-   ,0#-  NOTESTONOMINEE:  x    Pleaseenclosearecent3x5blackandwhite,glossy,headandshoulderphotograph,suitableforpublication.Attachadditionalpagestoshowthefollowinginformation:BusinessResponsibilities: (  Brieflydescribeyourprimaryactivityorresponsibilityinthebusiness,firm,orinstitution,suchasspecificationwriting,design,administration,promotion/marketing,fieldrepresentative,estimating/expediting,orotheractivities.Describemorethanoneresponsibility,ifapplicable.Ifyourfieldisengineering,pleasenotethediscipline.BusinessBackground: 8  Brieflylistprofessionalorbusinessbackground.ServicestoCSI: t  Showoffice(s),committeesappointments,awardsreceived,annualconventionsandregionconferencesattendedasdelegate,speakingengagements,orotheractivities.Denotecommitteechairmanshipbyanasterisk.Listalldatesconsecutively(notingboththemonthandyear),endingwiththemostrecentactivity.ListChapterservicefirst,followedbyRegionandInstituteservice.ListAwardsreceivedlast.GoalsasSouthwestRegionInstituteDirector: p BrieflydiscussyourgoalsfortheInstituteandtheSouthwestRegion.IacceptthenominationandagreetoserveifelectedasInstituteDirectorfortheSouthwestRegion.______________________  _________________________________ H# (Date)  (Signature) 4$   #XX6 #X6X#XX6p1#