Panel Nomination Form

Panelist Nomination
Panelist Nominee *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Day Phone *

Area Code Phone Number
Cell

Area Code Phone Number
Fax

Area Code Phone Number
Email Address *
Website
Has the Nominee previously served on MAC panel(s)
If Yes, which panel(s) and what fiscal year(s)
What experience and skills would help you serve as a MAC panelist? Describe your experience as an artist, administrator, teacher, volunteer, business professional. Note in what area of the arts you have expertise and if you have served on a panel or commission in another capacity. *
Attach Nominee Resume' *

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Optional Questions

In order to develop a panel that reflects Missouri's diverse populations, cultures and citizens, MAC is requestion information on the Nominee's back ground. The questions below are optional.
Gender (Choose One)
Age (Choose One)
Ethnic background

African/African American Asian/Pacific Islander Hispanic/Latino/Chicano Native American/Alaskan Native White/Not Hispanic Multicultural (more than one of the above racial/ethnic categories applies) Do not wish to answer
Should be Empty:

Panelist Nomination