Nebraska Administrative Code
Topic - EDUCATION, DEPARTMENT OF
Title 92 - NEBRASKA DEPARTMENT OF EDUCATION
Chapter 64 - PROCEDURES FOR NEGOTIATED RULEMAKING
Attachment 92-64-3

1. The undersigned person (the applicant) hereby applies for membership on the above-referenced negotiated rulemaking committee.

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Name of applicant (typed or printed)

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Full address of applicant

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Applicant's telephone number (including area code)

2. The applicant represents the following identifiable interest which will be significantly affected by the proposed administrative rule being considered by the above-referenced negotiating rulemaking committee:

3. The applicant is authorized to represent parties related to the interest listed above because:

4. The applicant can adequately represent the parties and interest listed above because:

5. Reasons that persons already serving on the above-referenced negotiated rule making committee do not adequately represent the interest listed in paragraph 2 above include:

6. In support of his or her application, the applicant has attached the following documents to this petition (list all attachments):

7. By signing this application, the applicant hereby certifies that he or she will represent the interest identified above to the best of his or her ability in the negotiation process, and that he or she is willing to actively negotiate in good faith to reach a consensus on the proposed rule being considered by the above-referenced negotiated rulemaking committee.

_________________________________ Date _____________________

Signature of Applicant

NOMINATION FOR MEMBERSHIP

(complete if applicable)