2021 COLLEGE STATE DELEGATE APPLICATION

Thank you for your interest in the College’s State Delegate position in the House of Delegates. Please complete the following application form. Applications are being accepted Jan. 15 – Feb. 26, 2021. All submitted applications will be vetted by the HOD’s Nominating Committee; one representative from each state will be chosen for a five-year term. All applicants will be notified of their status by June 1.

If your state is listed, the state delegate position was filled last year and will not become available again until 2025. State delegates have been chosen for: Alabama, Alaska, Arkansas, California, Connecticut, Florida, Georgia, Illinois, Indiana, Kentucky, Maryland, Michigan, New Jersey, Ohio, Texas, Virginia, Wisconsin, and West Virginia.

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* 1. Please provide your name and contact information.

Name (First Middle Last)

Email Address

Cell Phone Number

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* 2. Where do you practice? (If you have more than one office, list your main office.)

City/Town

State/Province

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* 3. List your relationships with: (organization names)

Political organization(s)

Community organization(s)

State medical society

Local allergy society

Regional allergy society

State allergy society

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* 4. Have you held leadership positions with any of the above organizations/societies?

Yes

If you answered yes, please list positions held (current/previous).

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* 5. List your relationships with: (names)

State legislators

Federal legislators

Lobbyists

2021 COLLEGE STATE DELEGATE APPLICATION

Question Title

* 1. Please provide your name and contact information.

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* 2. Where do you practice? (If you have more than one office, list your main office.)

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* 3. List your relationships with: (organization names)

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* 4. Have you held leadership positions with any of the above organizations/societies?

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* 5. List your relationships with: (names)

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* 6. Describe your prior advocacy-related work; include grassroots advocacy:

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* 7. List relevant accomplishments:

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* 8. Briefly explain why you want to be a state delegate: