PART I: Applicant Description

1.Full Name (w/ highest degree earned):

2.Email Address

*3.Declaration: I volunteer to run for the ASAHP office of (please mark one):(Required.)

Board of Directors (3 year term)

Secretary (2 year term)

Nominations & Elections Committee (2 year term)

4.Current Position: (Please include Position Title, School/College, Institution information, and address)

5.In the space below, please provide a statement (limit of approximately 500 words) about your background and aspirations for the Association. The information will be reproduced exactly as you submit it.

PART II: Prior Experiences

6.ASAHP Activities (list no more than five, formatting as shown below):
Activity I:
Activity II:
Activity III:
Activity IV:
Activity V:

7.Other relevant experience (list no more than five, formatting as shown below):
Experience I:
Experience II:
Experience III:
Experience IV:
Experience V:

PART III: Additional Information

8.Please include a head and shoulder photograph in jpg/jpeg/png format.  The photo should be approximately 1100 x 1640 pixels.

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9.Include an up-to-date CV (which will be reviewed but not published online).

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