Application Form I. General Information (Please print or type.) Applicant:  

P

ublic Risk Management Association

2018-2019 Board of Directors

Application Form

I. General Information (Please print or type.)

Applicant:      		Professional designations:      
Title:      		Entity:      
Address:      
City:      	State:      		Zip code:      
Phone (work):      		Phone: (home):      
Phone (cell):      		Fax:      
Email:      
PRIMA membership #      

II. Qualifications

1. 
   Current status:  Appointed  Elected  Other
   
2. 
   Employment status:  Full-time  Part-time
   
3. 
   Current duties (estimate percentage of time):
   

Risk management:       %

Other:      	      %	Other:      	      %
Other:      	      %	Other:      	      %

4. 
   Current and prior risk management experience (at least three years in a public entity required):
   

   Years	Entity
        	     
        	     
        	     
        	     
        	     
        	     

5. 
   How long have you been a member of PRIMA (including any and all employers)?
   

     

6. 
   Past PRIMA Annual Conference attendee (check all that apply):
   

 2017 Phoenix

 2016 Atlanta

 2015 Houston

 2014 Long Beach

 2013 Tampa

 2012 Nashville

 2011 Portland

 2010 Orlando

 2009 Dallas

 2008 Anaheim

 2007 Boston

 2006 Las Vegas

 2005 Milwaukee

 2004 Fort Lauderdale

 2003 Reno

7. 
   Applicant should have attended at least one of the past two PRIMA Annual Conferences. If not, please explain why.
   

     

8. 
   What has been your experience within PRIMA—PRIMA committee participation, chapter membership, chapter leadership or other PRIMA leadership roles?
   

     

9. 
   Please list any other boards on which you currently serve, or have served on in the past (community organization, religious organization, etc.)
   

     

10. 
    Educational background
    

     

11. 
    Please list any other risk management-related or relevant activities (may include past accomplishments, new programs, awards):
    

     

12. 
    Please list any other professional affiliations:
    

     
III. Entity information:

1. 
   Number of employees employed by your entity (full-time equivalent):      
   
2. 
   Number of employees responsible for risk management programs reporting to you:
   

Full-time clerical:       Full-time professional:      

Part-time clerical:       Part-time professional:      

3. 
   Total operating budget you for which you are responsible:      
   
4. 
   Population or full-time student equivalent of your entity:      
   
5. 
   Please check each area for which you are responsible, and elaborate below:
   

 Workers’ compensation

 Insurance procurement management

 Claims administration

 Owner-controlled insurance program

 Emergency management

 Pool governance

 Enterprise risk

 Risk control

 Employee benefits/HR

 Training

 Other, please list:      
Please attach a copy of your resume for review by the Leadership Development Committee.

IV. Supplemental information: Please type on separate sheets and attach.

1. 
   What do you enjoy most about risk management, and what are your long-term career goals in this area?
   

     

2. 
   Why do you want to serve on the PRIMA Board of Directors?
   

     

3. 
   Why should PRIMA’s Leadership Development Committee choose you over other candidates for a director’s position?
   

     

4. 
   What do you believe are the three biggest issues facing public risk managers today?
   

     

5. 
   What do you believe are the three biggest issues facing PRIMA today?
   

     

6. 
   Please add any other information that would be useful to the Leadership Development Committee, including an explanation of how you will help PRIMA develop and achieve its mission to be the leader in facilitating progressive public risk management education.
   

     
NOTE: Use additional sheets if necessary.

V. Entity Endorsement

Participation in PRIMA’s governance at the national level provides a unique opportunity for an individual to make a significant contribution in the field of public sector risk management, a contribution that will:

• 
  Enhance the well-being of public employees through the promotion of, and through education concerning, effective workplace health and safety programs.
  

• 
  Enhance the well-being of residents through the promotion of, and through education concerning, effective public liability loss prevention programs.
  
  
  
• 
  Enhance the financial well-being of public entities as entities learn the most cost-effective ways to manage risk, and through the significant dollar savings that accrue from effective risk control programs.
  
  
  
• 
  Enhance the financial well-being of your own public entity as you are exposed to the newest and most innovative risk management issues and developments through your involvement in public risk management at the national level.
  

Participation in PRIMA’s governance at the national level also carries with it certain time commitments, commitments of your personal time and commitments of time away from your office. It is for the later reason that PRIMA requires you secure the support of your entity for this important position.

You must have an endorsement of participation from your employing entity. It is up to you to determine the level in your organization required for a commitment such as this (supervisor, department director, etc.) However, this individual must have the authority to agree to your commitment to serve on the Board.
The following information should be helpful:

• 
  Directors each serve one three-year term (subject to additional commitment if director successfully seeks the position of president-elect).
  
  
  
• 
  Board meetings are usually held as follows:
  

Late February – 2 days	June - 5 days (includes Annual Conference)
Late September - 3 days	Early December – 1 day

• 
  Board assignments are conducted at various times and can generally be completed from your place of employment.
  
  
  
• 
  Board members may also be asked to visit chapters (at PRIMA’s expense).
  

• 
  Travel expenses will be covered as stated in the PRIMA Travel Policy.
  

I have read this application regarding (please fill in name)       desire to serve on PRIMA’s Board of Directors. Additionally, I understand the applicant’s obligations should he/she be elected to office and our entity is supportive of this involvement. To the best of my knowledge, the information presented herein is correct.

(Print) Supervisor’s, Department Director’s, or other authorized person’s name

Signature Date

I have read this application regarding service on PRIMA’s Board of Directors. I understand the obligations should I be elected to office and my entity is supportive of this involvement. To the best of my knowledge, the information presented herein is correct. Should I be chosen for an interview, I am available to travel to Alexandria, VA, on March 4-5, 2018.

Print Applicant’s Name

Applicant’s Signature Date

Please return this application and all supplemental documents by January 12, 2017, to:
Leadership Development Committee

PRIMA

700 S. Washington Street, Suite 218

Alexandria, VA 22314

You may fax your form to PRIMA at [phone] or email [e-mail].