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The Nominating Committee annually seeks recommendations for nominees.  Complete this nomination form to confirm your interest and give your consent in being considered for running for office. 

Nominations are due by midnight central time on Monday, June 6, 2022
About the Nominee

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* 1. Full Name and designations (as it appears in your APTA member profile):

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* 2. Select any designation that applies to you.

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* 3. Contact information

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* 4. APTA Geriatrics Membership ID #:

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* 5. Please rank the positions for which you would like to serve, and in order of preference (1 = most interested, 9 = least interested). Note that the Nominating Committee reserves the right to slate candidates for any position, regardless of their selection preferences (except for any positions of which they opt-out).

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* 6. Please select any positions of which you prefer to opt-out from:

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* 7. Please briefly describe for us what you believe to be your most significant accomplishments as a leader as it relates to advocacy for our profession. (150 words or less):

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* 8. Please describe the activities you've participated in to support APTA Geriatrics, APTA State Chapter and or the National APTA Organizations. Additionally, list any relevant not-for-profit leadership experience you may have.

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* 9. Is there any other information you would like the Nominating Committee to know about you as they determine the slate for this year?

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* 10. Summarize your answers to the questions above to create a brief bio to be published in the August issue of GeriNotes. (Tip: In 200 words or less, using first-person pronouns such as "I" or "me.")

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* 11. Please confirm:

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* 12. Please upload your curriculum vitae (CV) here:

PDF, DOC, DOCX file types only.
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* 13. Please upload your headshot here:

PNG, JPG, JPEG, GIF file types only.
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Thank you! We will review the information you have provided, and if we have any questions, we'll contact you during the vetting process. You will be notified via email whether or not you have been slated for a position. 

-The APTA Geriatrics Nominating Committee

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