ANA-MICHIGAN CONSENT TO SERVE - Committee

MEMBER INFORMATION

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* 1. PLEASE COMPLETE THE INFORMATION BELOW

Name: *

Credentials:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Home Phone:

Cell Phone: *

Preferred Email: *

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* 2. EDUCATION - highest level of education

DEGREE

SCHOOL

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* 3. EMPLOYMENT

EMPLOYER

PRESENT POSITION

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

Legislative Committee

Bylaws Committee

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

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* 6. If appointed to an ANA-Michigan 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
2. Conflict of Interest Policy

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

Name:

Date: