Community Resilience Panel Membership Application Form

Community Resilience Panel for Buildings and Infrastructure Systems Membership Application Form

The Member agrees to comply with all conditions and requirements as set forth in the Bylaws, as amended from time to time. All Members must identify a Stakeholder Category.

Member Information

Name: ­­­­­­­­­­­­­­

Title:

Organization:

Employer’s Principal Business:

Email Address:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

Telephone:

Stakeholder Categories (Please select one)

• Building Construction and Safety

• Businesses and Industry

• Community Planning

• Community Social Institutions

• Education and Research

• Facility Operations and Maintenance

• Federal, Tribal, Regional, State and Local Governments

• Insurance/Re-Insurance

• Public Health and Healthcare

• Relief Services

• Standards Development Organizations

• Vulnerable Populations

• Communication Systems

• Energy Systems

• Transportation Systems

• Water/Wastewater Systems

Standing Committee (Please select your primary and secondary standing committee interest)

Primary Standing Committee Interest (Please Circle One):	Secondary Standing Committee Interest (Please Circle One):
Buildings and Facilities Communications Energy Social and Economic Transportation Water and Wastewater Data, Metrics and Tools Nominations	Buildings and Facilities Communications Energy Social and Economic Transportation Water and Wastewater Data, Metrics and Tools Nominations

Statement of interest relating to the committee:

Relevant Expertise:

Key Interest Areas:

Supplemental Information:

• Relevant Experience:

• Education:

• Codes, standards and guidance development:

• Professional Associations:

This application collects and stores name, address, email address and telephone number, which the Department of Commerce considers to be non-sensitive personally identifiable information (PII). NIST will take reasonable precautions to protect PII transmitted by this application. The transmitted information can only be compromised as a result of theft, fraud, or other illegal activity. If you do not wish to accept this risk, please contact Nancy.McNabb@nist.gov to submit your membership application.

This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of Management and Budget (OMB). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the PRA unless that collection of information displays a currently valid OMB control number. Public reporting burden for this collection is estimated to be 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. Send comments regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the:

National Institute of Standards and Technology Attn: Stephen Cauffman, 100 Bureau Drive, Mailstop 8615 Gaithersburg, MD 20899 (301) 975-4447 stephen.cauffman@nist.gov

OMB Control No. XXXX-XXXX

Expiration Date: XX-XX-XXXX