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**Resource Advisory Council**

**Background Information Nomination Form**

[Name of council to be considered for]{.underline}: [(Circle
One)]{.underline}

Front Range Council Northwest Council Southwest Council

[Nominee\'s Full Name]{.underline}:

[Business Address]{.underline}: [Home Address]{.underline}:

[Business Phone]{.underline}: [Home Phone]{.underline}:

[Occupation/Title]{.underline}:

[Education: (colleges, degrees, major field of study)]{.underline}:

[Career Highlights]{.underline}: Significant related experience, civic
and professional activities, elected offices (if term expires, prior
advisory committee experience or career achievements related to the
interest to be represented). Attach additional pages as necessary.

[QUALIFICATIONS: Education, training and/or experience]{.underline}:

[Experience or knowledge of the council\'s geographic area of
jurisdiction]{.underline}:

[Experience in working with disparate groups to achieve collaborative
solutions (e.g., civic organizations, planning commissions, school
boards)]{.underline}:

[Indicate Specific Area of Interest to be Represented]{.underline}:

1.  I hold a Federal grazing permit, or other land use permit within the
    area for which the RAC is organized

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1.  I represent energy and mineral development interests

2.  I represent commercial timber industry interests

3.  I represent transportation or rights-of-way, off-highway vehicle
    use, or commercial recreation interests

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1.  I represent a nationally or regionally recognized environmental
    organization

2.  I represent archaeological and historic interests

3.  I represent dispersed recreation interests

4.  I represent wild horse and burro groups

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1.  I hold State elected office

2.  I hold county, or local elected office

3.  I am an employee of a State agency responsible for management of
    natural resources

4.  I am an academician involved in natural sciences

5.  I represent Indian tribes

6.  I represent the public-at-large

[Indicate any BLM permits, leases or licenses that you
hold:]{.underline}

**Attach Letters of References from interests or organizations to be
represented (required):**

[Nominated by]{.underline}:

[Name Address, and Phone Number]{.underline}:

[Privacy Act Statement]{.underline}

The authority to request this information is contained in 5 U.S.C. 301,
the Federal Advisory Committee Act, and Part 1784 of Title 43, Code of
Federal Regulations. It is used by the appointment officer to determine
education, training, and experience related to possible service on a
Resource Advisory Council of the Bureau of Land Management. If you are
appointed as an advisor, the information will be retained by the
appointing official as long as you serve. Otherwise, it will be
destroyed 2 years after termination of your membership or returned (if
requested) following announcement of the Council appointments.
Completion of this form is voluntary. However, failure to complete any
or all items will inhibit fair evaluation of your qualifications, and
could result in you (or your nominee) not receiving full consideration
for appointment.

Signature: Date:

**Send this signed and dated form with LETTERS OF REFERENCE AND ANY
ATTACHMENTS to the appropriate office below:**

[FRONT RANGE COUNCIL NORTHWEST COUNCIL]{.underline} [SOUTHWEST
COUNCIL]{.underline}

Front Range RAC Northwest RAC Southwest RAC

Attn: RAC Nomination Attn: RAC Nomination Attn: RAC Nomination

3170 East Main Street 2815 H Road 2815 H Road

Cañon City, CO 81212 Grand Junction, CO 81506 Grand Junction, CO 81506

**[CONTACT FOR ADDITIONAL INFORMATION]{.underline}**

KEN SMITH STEVEN HALL STEVEN HALL

719.269.8500 970.244.3052 970.244.3052