ANVC Candidate Nomination Application

Nomination applications must be submitted electronically
The information provided in the application will be reproduced as presented for the ballot
If you have questions, please email nominating-committee@anvc.org

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* 1. Position for which you are submitting for:

Board of Directors

Nominating Committee

Certification-Membership Committee

Education Committee

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* 2. Contact Information

Name

Company

Address

City/Town

State and Zip Code

Time Zone (Interviews will be held via telephone)

Email Address

Home Phone Number

Work Phone Number

Cell Phone Number

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* 3. Candidate Statements

Please upload your written statement of 250 words or less addressing the following issue: Describe your vision for neurovascular clinical practice and the role of the ANVC.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 4. Please upload a brief CV (no more than five pages) that highlights your Education, Credentials, Awards, etc.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 5. Please upload a photo in .jpg format

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 6. I will provide the ANVC with references using the ANVC Candidate Reference Form.

Yes

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* 7. I have read and agree to abide by ANVC's Conflict of Interest and Confidentiality Policy if elected to the Board or selected for a Committee position and agree to disclose all conflicts of interest.

Yes

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* 8. CONFLICT OF INTEREST DISCLOSURE FORM

No, I have no relevant personal, financial and/or "competitive" relationships

Yes, I do have personal, financial and/or "competitive" relationships (If yes, proceed to next question)