MEMBER INFORMATION

* 1. PLEASE COMPLETE THE INFORMATION BELOW

* 2. EDUCATION - highest level of education

* 3. EMPLOYMENT

* 4. I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT/ASSIGNMENT TO THE FOLLOWING POSITIONS.

* 5. Please give a brief summary of your experience and/or interest in serving in position(s) selected above.

* 6. If appointed to the ANA-Illinois Board of Directors, Committee or Taskforce, 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
2. Board of Directors Confidentiality Agreement
4. Conflict of Interest Policy

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

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