Skip to content
2025 ANA-ILLINOIS ELECTIONS CONSENT TO SERVE
MEMBER INFORMATION
*
1.
PLEASE COMPLETE THE INFORMATION BELOW
(Required.)
Name:
*
Credentials:
Address:
*
Address 2:
City/Town:
*
State:
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
*
County:
*
Cell Phone:
*
Preferred Email:
*
*
2.
Which of the following most accurately describe(s) you?
(Required.)
Female
Male
Non-binary
Transgender
Intersex
I prefer not to say
Other (please specify)
*
3.
Race/Ethnicity (Select all that apply.)
(Required.)
American Indian or Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
Asian
Hispanic/Latino or Spanish Origin
White/Caucasian
I prefer not to answer
Other (please specify)
*
4.
What are your pronouns?
This helps us understand the best way to address you
(Required.)
She/her
He/him
They/them
I prefer not to say
Other (please specify)
*
5.
EDUCATION - highest level of education
(Required.)
DEGREE
SCHOOL
*
6.
EMPLOYMENT
(Required.)
EMPLOYER
PRESENT POSITION
*
7.
I CONSENT TO HAVE MY NAME CONSIDERED FOR NOMINATION TO THE FOLLOWING ELECTED ANA-ILLINOIS OFFICES AND/OR AS A REPRESENTATIVE TO THE ANA MEMBERSHIP ASSEMBLY.
I understand that I cannot be elected to serve as an officer or director if such election or service could result in concurrent membership on the ANA-Illinois Committee on Nominations.
All terms are for 2 years.
(Required.)
PRESIDENT
SECRETARY
DIRECTOR (2 to be elected)
NOMINATIONS COMMITTEE (2 to be elected)
ANA REPRESENTATIVE [2 reps/1 alternate to be elected]
