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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 Tuesday, June 6, 2023.

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* 1. Your full name with designations, as it appears in your APTA member profile (please use the designations style guide below):

Designations Style Guide
Designations should be listed in the following order:
  1. FIRST designation: PT or PTA
  2. SECOND designation: Highest earned physical therapy-related degree (such as DPT or MPT)
  3. THIRD designation: Other regulatory designation(s) issued by government entities (such as OT, EMT, RN)
  4. FOURTH designation: Other earned academic degree(s) from a bona fide college or university (such as PhD, MBA, MEd, DSc, MPH)
  5. FIFTH designation: FAPTA
Correct Example: John Doe, PT, DPT, RN, PhD, FAPTA
Incorrect Example: John Doe, FAPTA, DPT

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* 2. Select any of these additional designations that apply to you:

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* 3. Your Contact information:

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* 4. Your APTA Geriatrics Membership ID #:

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* 5. Please review the positions and indicate whether or not you'd like to be considered for each.

Helpful tips:
  • You can select "I DO" or "I DO NOT" for as many or as few positions as you'd like.
  • For any positions that you select "I DO," the nominating committee WILL consider you for that/those positions.
  • For any positions that you select "I DO NOT," the nominating committee WILL NOT consider you for that/those positions.
  • A part of the vetting and slating process will require a live interview with the nominating committee for all positions listed in green font. No interview will be required for positions listed in black font.
  • You will be asked to rank these in Question 6.

  I DO want to be considered for this position I DO NOT want to be considered for this position
Board of Directors: President (3 year term)
Board of Directors: Vice President (3 year term)
Board of Directors: Director (3 year term)
Nominating Committee: Member (3 year term)
Balance and Falls SIG: Secretary (3 year term)
Bone Health SIG: Secretary (3 year term)
Cognitive and Mental Health SIG: Secretary (3 year term)
Global Health for Aging Adults SIG: Vice Chair (2 year term)
Global Health for Aging Adults SIG: Secretary (3 year term)
Health Promotion and Wellness SIG: Secretary (3 year term)
Residency and Fellowship SIG: Vice Chair (2 year term)
Residency and Fellowship SIG: Secretary (3 year term)

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* 6. Based on the position(s) above (in question 5) that you indicated you DO want to be considered for, please rank them in order of your preference. If you have no preference, then skip this question.

Helpful tips:
  • The position you MOST prefer should be listed as #1
  • Any position(s) that you selected "I DO," in question 5, should have a # listed in drop-down box.
  • You can either drag and drop positions to indicate ranking order, or make a selection from the drop-down box.
  • No positions can have the same ranking #.
  • For any positions that you selected "I DO NOT,"  in question 5, please indicate "N/A - I DO NOT want to be considered for this position." 

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* 7. Please describe 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. (150 words or less)

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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. Please upload your curriculum vitae (Note: the file name must include your first and last name; please limit your CV to no more than 3 pages of relevant experience).

PDF, DOC, DOCX file types only.
Choose File

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* 11. Please upload your headshot (Note: the file name must include your first and last name)

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 12. Please confirm:

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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