Part I: General Information

First Name:      
Last Name:      
Professional Title:       
Street Address Line 1:      
Street Address Line 2:  
Applicant Phone:      
Applicant Cell:  
Applicant Fax:  
Provide evidence of your knowledge and qualifications for the category selected (describe below or attach extra pages if needed).  

Part 2: Category Interest


Producer/Retailer – Producers or retailers of manufactured housing.

User/Consumer – Persons representing consumer interests, such as consumer organizations, recognized consumer leaders, and owners who are residents of manufactured homes.

General Interest and Public Officials

Interest Category:       

Part 3: Employer/Employment

Employer Name:        
Employer AddressL1:     
Employer AddressL2:  
Employer Address City:     
Employer State:     
Employer Zip:     
Your Emploment Position:     
Your Employment Duties:
Your Employment History:
Identify the background and description of the business of your employer.
Explain if your current employment is related to the interest category you seek.

Part 4: Financial Independence

A significant financial interest in any segment of the manufactured housing industry?
A significant relationship to any person engaged in the manufactured housing industry?
Will you be able to actively participate in the work of the MHCC, including responding to correspondence and attending committee meetings?
Additional comments or information:  

If appointed as an MHCC member, I agree to undertake the responsibilities required by the National Manufactured Housing Construction and Safety Standards Act MHCC Charter, By-laws, and other applicable requirements. In addition, I agree to notify the Administering Organization and the HUD Secretary of a change in status, including change of employment, organization represented, potential conflicts of interest, and, if required, an annual certificate of financial independence.


I certify that all of the information on this application is true and accurate.