Application for Nomination

Application for Nomination

Low-Income Representative Park County Tripartite Board
The Yellowstone Country Assistance Network is a non-profit organization that serves Park and Hot Springs Counties in Wyoming. We operate under a tripartite board that must include diverse representatives. This includes 1/3 of the membership being democratically selected representatives of low-income individuals and families, 1/3 being public office elected officials, and 1/3 representing significant groups in the community.

This is all based on the Federal CSBG Act and the Community Services Block Grant Reauthorization Act of 1998. These laws mandate that private non-profit entities and public organizations administer their CSBG program through tripartite boards. The Yellowstone Country Assistance Network complies with these requirements to ensure that they serve the community fairly and effectively.
The Federal CSBG Act does not mandate that representatives be low-income themselves. However, it is crucial to have as many low-income individuals as possible, even if serving on an advisory council, to ensure that the voice of the low-income people served is represented since they have a better understanding of their specific needs.

To be eligible, you must meet the following criteria:
1. You must be at least 18 years old.
2. You must have lived in the county and community for at least one year.
3. You must have been democratically selected to represent low-income people in the Corporation’s service area.
4. You are not required by federal statute to be low-income or meet low-income sector guidelines, which means your income must be at or below 125% of the threshold.
5. The Board is responsible for final approval of Low-Income Representatives to the Board.
6. If selected, you agree to participate in board orientation training.
Applicant Nominee Name*

First NameLast Name
Applicant Nominee Address*

Street Address

Mailing or PO Box if different than mailing

CityState / Province

Postal / Zip Code
County of Residence?*

Park CountyHot Springs County
Applicant Nominee Phone Number*
Applicant Nominee Email
example@example.com
Which board sector do you best qualify for?*

Representing Customer Base (low-income)Customer Base (low-income)Elected Public OfficialMajor groups of interestI am petitioning for representation on the board
Candidate Profile (to be printed on ballots)
Sample Candidate Profile:

Hi there! My name is [Your Name], and I am honored to be a candidate for the low-income community representative position. As a resident of _____ community who has experienced financial hardship, I understand the daily struggles of low-income families. That’s why I am committed to advocating for policies that will improve the lives of those struggling to make ends meet.

My experience in community organizing and activism has given me the skills necessary to create positive change. I have worked with community members to organize events, to educate people about their rights, and to advocate for policies that will uplift our community. I believe that everyone deserves to live with dignity and respect, and I will work tirelessly to ensure that our community is a place where everyone can thrive.

If elected, I will be a voice for the voiceless. I will work to increase access to affordable housing, healthcare, and education. I will fight for a living wage and protections for workers. I will also work to ensure that our community is safe and that our children can access quality education.

I am grateful for the opportunity to serve our community, and I promise to work hard daily to represent the needs and concerns of low-income families. I appreciate your consideration.
What community/neighborhood do you wish to represent on our board?*
"What are the poverty issues that you are passionate about solving?
Your success as a low-income representative hinges on your ability to effectively involve and engage the citizens you seek to serve. Can you please elaborate on your strategies to ensure that their voices are heard and their needs are met?
Your Occupation
Your Employer (if employed)
Employer Phone Number
If you have no professional or employment experience, please provide 2 personal references (not related to you) who can speak to your abilities and experiences. Kindly include their contact information.
What characteristics or skill do you have that you believe would benefit YCAN if you are selected as a board member?

Financial ExperienceGrant WritingGrant ManagementCommunity RelationsEducationMarketingFundraisingLegalEconomic DevelopmentHousing DevelopmentSocial WorkOrganizational PlanningLow-Income IssuesGovernment RelationsBusinessPovertySelf-SufficiencyOther
Please provide a list of any previous experience you have had as a volunteer or board member for a non-profit organization.
Could you please provide a list of any training you have received that you believe would be valuable for YCAN?
Your skills and expertise will be invaluable in helping YCAN achieve its goals. So, why would you like to be a volunteer board member for YCAN? Your participation could make a significant impact on the lives of many individuals.
Our Mission:

In partnership with local service providers, empower people living in the Big Horn Basin of Wyoming to enhance health, housing, and employment status, overcome obstacles, and end economic hardship.
Please write a short statement explaining your comprehension of YCAN's mission statement.*
What are the opportunities or challenges related to poverty in your community?
Your Ability to Serve
Date of Birth

YearMonthDay
Date
I confirm that I have not been found guilty of or held liable for committing fraud or a criminal offense related to obtaining, attempting to obtain, or performing a public transaction or contract under a public transaction, violating federal or state antitrust laws, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

YesNo
I currently not facing any criminal or civil charges by any governmental entity for the offenses listed above.

TrueFales
I have not had any federal, state, or local transactions terminated for cause or default in the past three years.

TrueFalse
"I confirm that I am not under any debarment, suspension, or ineligibility from any federal agency. YCAN, the organization I am applying to be a board member of, will check my name against the "Excluded Parties List System" database to ensure that I am not disqualified from participating in any federal grant or contract programs. The database is accessible online at www.epls.gov."

YesNo
Nominee Signature: I declare that the information provided in this application is true and accurate to the best of my knowledge.*

Clear
Date*

YearMonthDay
Date
Should be Empty:

Application for Nomination

Your Ability to Serve