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ANA-ILLINOIS CONSENT TO SERVE - APPOINTED POSITIONS

MEMBER INFORMATION

1.PLEASE COMPLETE THE INFORMATION BELOW(Required.)
2.Which of the following most accurately describe(s) you?(Required.)
3.Race/Ethnicity (Select all that apply)(Required.)
4.What are your pronouns? This helps us understand the best way to address you
5.EDUCATION - highest level of education(Required.)
6.EMPLOYMENT (Required.)
7.PREFERRED POSITION.
I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT/ASSIGNMENT TO THE FOLLOWING POSITIONS  - Choose one.(Required.)
8.IF NOT APPOINTED TO MY PREFERRED POSITION, I WOULD CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT/ASSIGNMENT TO THE FOLLOWING POSITIONS (Required.)
9.Please give a summary of your experience and/or interest in serving in the position(s) selected above. Be sure to list other volunteer experiences, board and/or committee service.(Required.)
Although the pronunciation of many names is obvious, some require special attention. If your name is one that
is pronounced in a special way, please use the key below to advise us how your name should be pronounced.

Indicate either the phonetic spelling of your name OR a familiar word that rhymes with your name.

Phonetic Spelling Instructions
10.Phonetic spelling of your name.
11.If appointed by the ANA-Illinois Board of Directors to a committee, it is my obligation to attend meetings and do the work of the position. If I am unable to fulfill this commitment, I will resign.

Upon appointment, I will receive links to the following forms that must be completed prior to the first committee meeting.
1. Volunteer Participation Agreement
4. Conflict of Interest Policy

Completion of the line below serves as the electronic signature of the individual completing this form.(Required.)