Committee/Task Force Request

Name (Person submitting request) *

Applicant Email *

Applicant Telephone Extension *

Proposed Committee/Task Force Name *

Proposed Committee/Task Force Purpose *

Proposed Committee/Task Force Chair *

Chair Email *

Chair Telephone Extension *

If you are requesting a committee, the ongoing purpose and charge of the committee will be reviewed annually. If you are requesting a task force, you will need to give a beginning and end date for the task force.

I am Requesting

A Committee
A Task Force

Membership

Indicate proposed committee or task force membership below. Note that these are requests and they are subject to change based on current committee/task force assignments, individual skills, availability, and other factors. If the work of the committee or task force requires more than ten (10) members, please attach an explanation regarding the need for additional members.

Member 1 Name

Member 1 Department/Division

Member 1 Title

Member 1 Term Length

Member 2 Name

Member 2 Department/Division

Member 2 Title

Member 2 Term Length

Member 3 Name

Member 3 Department/Division

Member 3 Title

Member 3 Term Length

Member 4 Name

Member 4 Department/Division

Member 4 Title

Member 4 Term Length

Member 5 Name

Member 5 Department/Division

Member 5 Title

Member 5 Term Length

Member 6 Name

Member 6 Department/Division

Member 6 Title

Member 6 Term Length

Member 7 Name

Member 7 Department/Division

Member 7 Title

Member 7 Term Length

Member 8 Name

Member 8 Department/Division

Member 8 Title

Member 8 Term Length

Member 9 Name

Member 9 Department/Division

Member 9 Title

Member 9 Term Length

Member 10 Name

Member 10 Department/Division

Member 10 Title

Member 10 Term Length

If the work of the committee or task force requires more than ten (10) members, please attach an explanation regarding the need for additional members.

Expected number of meetings per academic year

Shared Governance

Committee/Task Force Request

Membership