Senior Examiner Application

APPLICATION FOR THE GOVERNOR’S QUALITY AWARD

2010 BOARD OF EXAMINERS

Thank you for your interest in becoming an Examiner. You may mail or e-mail your application. To be eligible for consideration your original application must be received or postmarked no later than March 31, 2010. If you have any questions, call the GQA office at 501-372-2222 in Little Rock.

Last Name

First Name

M.I.

Job Title

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Home Mailing Address

City

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Zip

Email Address

Work Phone + area code:

Home Phone + area code:

Work Fax + area code:

Cell Phone + area code:

Preferred Phone:

Click for WORK Click For HOME

Preferred Mailing Address:

Click for WORK Click For HOME

Cancellation Fee - $100 April 28-29 - Pulaski Technical College, 3000 West Scenic Drive, North Little Rock

Name Preference on Certificate (Use of one degree or credential is optional):

List up to five NAICS Codes most relevant to your expertise (Separate entries by comma)

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