2023 ANA-ILLINOIS ELECTIONS CONSENT TO SERVE

MEMBER INFORMATION

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* 1. PLEASE COMPLETE THE INFORMATION BELOW

Name: *

Credentials:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

County: *

Cell Phone: *

Preferred Email: *

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* 2. Which of the following most accurately describe(s) you?

Female

Male

Non-binary

Transgender

Intersex

I prefer not to say

Other (please specify)

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* 3. Race/Ethnicity (Select all that apply.)

American Indian or Alaskan Native

Black or African American

Native Hawaiian or other Pacific Islander

Asian

Hispanic/Latino or Spanish Origin

White/Caucasian

I prefer not to answer

Other (please specify)

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* 4. What are your pronouns? This helps us understand the best way to address you

She/her

He/him

They/them

I prefer not to say

Other (please specify)

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* 5. EDUCATION - highest level of education

DEGREE

SCHOOL

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* 6. EMPLOYMENT

EMPLOYER

PRESENT POSITION

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* 7. I CONSENT TO HAVE MY NAME CONSIDERED FOR NOMINATION TO THE FOLLOWING ELECTED ANA-ILLINOIS OFFICES AND/OR AS A REPRESENTATIVE TO THE ANA MEMBERSHIP ASSEMBLY.

I understand that I cannot be elected to serve as an officer or director if such election or service could result in concurrent membership on the ANA-Illinois Committee on Nominations.

All terms are for 2 years.

PRESIDENT

SECRETARY

DIRECTOR (2 to be elected)

NOMINATIONS COMMITTEE (2 to be elected)

ANA REPRESENTATIVE [2 to be elected]