Private Company Director |

I am nominating the board of (company name):

City and state where company is headquartered:

My name:

Country (if non-U.S.):

Country

My relationship to this board:

My email address:

My phone number:

My assistant’s name, email address and phone number (Optional):

Contact person for more information about this board (chairman or CEO preferred):

Board contact’s email address:

Board contact’s phone number:

Assistant to board contact: Name, email address and phone number (Optional):

Type of private board:

Company revenues:

Company ownership:

Why I am nominating this board: (Please be as specific as possible)

Attach supporting material here: (Optional)

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