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1. Name: (Required.)

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2. Position nominating for:

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3. Email: (Required.)

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4. Phone: (Required.)

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5. Region: (Required.)

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6. How many years have you been an ASCP Member? (Required.)

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7. How have you been involved with ASCP? (Please list all committees, leadership groups, chapter involvement, task forces, etc.) (Required.)

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8. Please list the ASCP meetings (national and regional) you have attended in the past 5 years: (Required.)

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9. Please list other Boards and/or Leadership groups you serve on, and the related organizations/associations: (Required.)

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10. What strengths do you feel you will bring to the ASCP Board? (Required.)

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11. Please tell us a little about yourself, your practice setting, company, and experience:
Why would you like to serve on the ASCP Board of Directors? (Required.)

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