2015 National Urban and Community Forestry Advisory Council
Call for Nominations
NOMINATION COVER SHEET
Nominee:
________________________________________________________
Title:
________________________________________________________
Organization:
________________________________________________________
Mailing Address:
________________________________________________________
Phone Number (s)
________________________________________________________
Fax Number:
____________________________
E-mail address:
____________________________
THE ABOVE NAMED NOMINEE WOULD LIKE TO BE CONSIDERED FOR THE FOLLOWING
POSITION(S):
____1: National Non-Profit Forestry and
Conservation Citizen Organization (first of two positions).
12/31/2015
____2: National Non-Profit Forestry and
Conservation Citizen Organization, (second of two positions).
12/31/2016
____3: Member Representing State Government.
12/31/2016
____4: Member Representing County Government.
12/31/2016
____5: Member Representing City and Town Government.
12/31/2015
____6: Forest Products, Nursery, or Related Industries.
12/31/2014*
____7: Urban Forestry, Landscape, and Design Consultants.
12/31/2015
____8: Academic Institutions with an Expertise in Urban
and Community Forestry activities, (first of two positions).
12/31/2014*
____9: Academic Institutions with an Expertise in Urban and
Community Forestry activities (second of two positions).
12/31/2015
____10: Member Representing State Forestry Agencies
12/31/2014*
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
____11: Member Representing a Professional Renewable Natural Resource
or Arboriculture Society.
12/31/2015
____12: USDA Extension Service.
12/31/2014*
13: USDA Forest Service. - Not Available
N/A
____14: Member from a Community with a Population less than
50,000 and is active in urban and community forestry.
They may not be an officer or employee of any government body.
12/31/2015
____15: Member from a Community with a Population greater than
50,000 and is active in urban and community forestry.
They may not be an officer or employee of any government body.
12/31/2014*
*2014 Expired positions are currently under Departmental review and pending the Secretary of
Agriculture’s appointment.
These term positions in bold will serve from 1/1/2016 through 12/31/2018. The maximum number
of terms a member may serve is two consecutive terms.
Those nominees selecting one of the national non-profit organizations, academic institutions, or
societies should include a letter of support from the leadership of that national organization,
department or society. Self-nominations are accepted. If eligible, nominees may select more than
one position. Please use a separate nomination form for each position.
Nominated by:
________________________________________________________
Signature
Date
________________________________________________________
Printed name
Title:
Organization:
Mailing Address:
Phone Number:
Email:
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Applications: Please use this nomination cover sheet and format as shown, the completed AD-755 form hand
signed by the nominee, and any additional applicable information.
We continue to accept applications for all position, however those in bold will be the only ones filled for
2016. Other position applications will be held and included on the nomination slate when the position
becomes available.
Hard-copy nominations “received” (not postmarked) by, November 30, 2015 for 2016 Nominees will
be considered. Facsimiles submissions will not be accepted.
Please email (subject line: 2015 nomination for 2016 positions). Please encrypt email to protect information
and send the password in a separate email to nstremple@fs.fed.us .
Or for courier or hardcopy mail, please send to:
Nancy Stremple,
National Program Specialist,
Urban and Community Forestry,
U.S. Forest Service
201 14th street, SW,
Sidney Yates Building 3rd Floor, (MS-1151),
Washington D.C. 20250-1151,
202-205-7829
nstremple@fs.fed.us
APPLICATION TEMPLATE (See Appendix A at the end of this application for an example of
how the final document of information should appear)
Please use the following format to describe how your work experience and education supports the
urban forestry related position(s) you have selected to represent.
Name:
City/State:
Job Title/Work Organization:
Brief Applicable Work History: (List current to past)
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Education: (List)
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Committees: (List, if applicable)
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Boards: (List, if applicable)
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Certifications: (List, if applicable)
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Is the nominee currently serving on any other Federal Advisory Committee Act (FACA)
related Councils? Yes, if yes, list:
No
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Provide supporting work and educational experience as it applies to the position you wish to represent:
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How do you plan to engage/ network with the stakeholder group you wish to represent?
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Additional Space:
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Additional Space:
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
REPRODUCED LOCALLY: Include form number and date on all reproductions.
0505-0001
Form Approved OMB No.
OMB Expiration Date: 5/31/2015
United States Department of Agriculture
ADVISORY COMMITTEE OR RESEARCH AND PROMOTION
BACKGROUND INFORMATION
[National Urban and Community Forestry Advisory Council]
Privacy Act Notice
Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine qualifications,
suitability and availability for service on advisory committees or research and promotion boards/councils. The information will be used to
conduct background clearances and/or for annual reports on advisory committees or research and promotion boards/councils. Failure to submit
this information may result in non-selection of a prospective advisory committee member, board/council member or termination of the committee
or board/council.
PLEASE PRINT CLEARLY OR TYPE
1. Name (Last, First, Middle) – Mr., Mrs., Miss., Ms., Dr.
2. Social Security Number:
Passport Number and Issuing Country: (foreign
citizens only)
3. Residence Address (include ZIP code)
4. Business No.
Home No:
Cell or Mobile:
FAX:
e-Mail Address:
5. Place of Birth
6. Date of Birth
7. This information is Voluntary and data will not be used to grant preferential treatment: (See last page for definition of
categories.)
What is your gender?
Ethnicity:
What is your race? (Mark all that apply)
___ Male
___ Hispanic or Latino
___ American Indian or Alaska Native
___ Female
___ Not Hispanic or Latino
___ Asian
___ Black or African American
___ Native Hawaiian or Other Pacific Islander
___ White
8. Company/Business Name
9. Company/Business Address (include ZIP Code)
9a. Occupation/Title
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Call for Nominations
10. [Insert appropriate commodity question(s) from supplemental list.] (To be completed by R&P Board Members Only)
Not Applicable to this FACA Committee
10a. If applicable, how long have you been engaged in farming or production, and what is the size of your farming
operation. (I.E. List acreage and pounds produced by kind of crop, as well as, kinds and numbers of livestock?)
Not Applicable to this FACA Committee
11. List your business experience. (Use the Continuation Sheet for additional space to answer.)
12. List education and any specialized experience. (Use the Continuation Sheet for additional space to answer.)
13. List applicable farm/handler/producer/importer or co-op member industry organizations (indicate whether a member
or officer and how long affiliated).
Not Applicable to this FACA Committee
14. List other affiliations and/or service as a community leader that would benefit you in your role as a member of the
advisory committee or research and promotion board/council.
15. List any Federal advisory committee or board on which you are currently a member and the number of years you
have served on that committee or board. (To be completed by current Advisory Committee Members Only)
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
16. List sources of income in excess of $10,000 for the past calendar year from other than your primary employment.
List only sources; do not show amounts of income from each source. (To be completed by Advisory Committee Nominees
Only)
_________________________________
_____________________________________
_________________________________
_____________________________________
17. Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by imprisonment
of longer than one year). ( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.
18. As a result of your participation in Federal programs, have any judgments been rendered against you? As a result of
participation in any governmental programs relative to the purposes of the advisory committee or research and
promotion board/council for which you are a nominee, have any civil or criminal actions been initiated against you?
( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.
19. Name as you would prefer it to appear on official correspondence.
Signature
Date
REPRODUCED LOCALLY: Include form number and date on all reproductions.
0505-0001
Form Approved O.M.B. No.
OMB Expiration Date: 5/31/2015
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Continuation Sheet for Form AD-755
If you need more space for an answer, use this sheet. Please number each answer to correspond to the number on Form
AD-755. When you have completed your answer(s), attach to Form AD-755.
[INSERT COMMODITY BOARD, COUNCIL, OR DELEGATE NAME]
Name (Last, First, Middle)
Social Security or Passport Number:
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0001. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Te U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender,
religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s
TARGET center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,
Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Form Approved O.M.B. No. 0505-0001
OMB Expiration Date 5/31/2015
Definition of Ethnicity and Race Categories
Ethnicity:
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race.
Race:
American Indian or Alaska Native – A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains tribal affiliation or community
attachment.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.
White – A person having origins in any of the original peoples of Europe, the Middle East or North
Africa.
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
Appendix A: Example Format for Nominee Information:
(Below is an example of how the application information is to be organized. All information is hypothetical
to demonstrate the format. Applicants may note on their AD-755 to refer to the applicant’s core information
page to reduce duplication.)
Position X: National Urban and Community Forestry
Irma Tree
 Dogwood, IL
 Job Title/Work Organization:
- President/ CEO National Natural Resource Economic Policy Center March 1, 2013 – Present,
- Urban Ecology Advisor, The Natural Resource Committee & 7th Ward Economic Recovery
Committee – Ms. Tree focused on ethnography, ethno-biology, cultural/natural resource management,
and identity. Over the past ten years she has worked on a variety of anthropological fields including
cultural/ natural resource management, historic landscape preservation, urban ecology program
development, landscape scale natural economic cost benefit curriculum development, and numerous
cultural programming, and climate change forensic analysis.
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Brief Applicable Work History: (List current to past)
- June.1, 2011- Present, Post-Doctoral Research Fellow- Community Based Citizen Science: Engage
community members of all ages in cultural/natural resource management and environmental and
economic policy.
- September 2008 to June 1, 2011 BS Planning etc.
- June xx to January xx, xxxxxx
- August to January, xxx
 Education:
- May, 2011 Doctoral Program xxxxxx, The University of USA
- May 2005 Master of Economics, The University of USA
- May, 1997 Bachelor of Science degree in Urban Forestry, University of State
- Lambda Alpha Anthropology Honors Society
- Phi Kapa Phi National Honors Society
- March, 2005 Master’s Thesis Research: xxxx etc.
 Committees:
- August 2006-May 2007 Vice-President, Montana Anthropology Student Association
- 2000 – Present, State Urban Forestry Council - Served in past positions Chair, Treasurer, Outreach
- June 2010 to 2014 Governor’s Committee on Climate Change
- Month/Year xxxxxxx etc.
Member, American Planning Association
- Chair, Regional Green Building Committee
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Boards:
- Board of Directors, Coalition to Restore Urban Waters
- Chair, City Planning Commission (CPC) 2008-2014
-
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2015 National Urban and Community Forestry Advisory Council
Call for Nominations
 Certifications:
- April 2010 to present Tree Keepers Certification, Badge # 1012, TreeKeepers is a program sponsored
through Openlands (Illinois) that trains people to manage trees within the City of Chicago, Park
District, and County Forest Preserve Districts.
- 2011 ISA Arborist Certification
- 2014 Certified Planner # 456 Skills Training for Trainers Program
Is the nominee currently serving on any other Federal Advisory Committee Act (FACA)
related Councils? Yes, if yes, list:
No X
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Provide supporting work and educational experience as it applies to the position you wish to represent:
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Volunteer for the annual community tree planting event. Organized and trained high school students
who earned college credits and volunteer hours. High school students then conduct a train the trainer
program for middle school and elementary school students and teach a Nature Play science
educational course.
Serve on the county planning commission to implement green infrastructure into our planning codes
and to inter connect with city and regional planning commissions. The collected effort addressed our
storm water compliance issues, saving us thousands in fees and saved us millions of not having to
build a new storm water treatment plant.
In addition, the green infrastructure pedestrian ways, included in the plan attracted more people to our
downtown areas increasing our economy.
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How do you plan to engage/ network with the stakeholder group you wish to represent?
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I have developed an email list serve to send Council information and activities to the group I
represent and ask them to send concerns and opportunities to me to be discussed with the Council.
I plan to propose to the Council to set up a Facebook page to share Council information.
Additional Space:
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