Thank you for your interest in volunteering for the ACMP Midwest Chapter as a member of the Board of Directors! Please complete this interest form by June 14, 2019 to be considered as a candidate for a Board of Directors position for the 2019/2020 term.

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* 1. Are you an ACMP member?

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* 2. Have you been a member of ACMP for at least one year (now or in the past)?

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* 3. Please provide the following information:

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* 4. Please indicate your preferred email address:

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* 5. Please indicate your preferred Board of Director Position. Be sure to read the position descriptions attached to the initial email .

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* 6. Have you served on an ACMP volunteer committee before?

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* 8. Why are you interested in serving as a Director on the Board for ACMP Midwest?

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* 9. Please share what skills and experience you have to contribute as a Board Director. (Be specific as it might relate to the areas for which you are interested)

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* 10. Please describe your previous Board experience (if any) you've had with a not for profit organization.

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* 11. Please answer the following ethics questions:

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Have you ever been found by any professional association to which you have belonged to have violated its ethical code or are you currently under investigation for an alleged ethical violation by any professional association to which you belong?
Are you involved in any relationships, personal, professional or otherwise directly or indirectly, which may raise a potential conflict of interest regarding your service to ACMP?
Do you have any contractual or financial relationship with ACMP Midwest? (i.e. sponsorship)
Do you agree to adhere to the ACMP Code of Ethics and Professional Conduct?
Do you agree to fully disclose to the Board of Directors any potential conflicts of interest related to any relationships?
Do you agree to fulfill the Duty of Care? A legal responsibility to participate actively in making decisions on behalf of the organization and to exercise his or her best judgement while doing so.
Do you agree to fulfill the Duty of Loyalty? A responsibility to put the interests of the organization before his or her own personal and professional interests when acting on behalf of the organization in a decision-making capacity. The organization's needs come first. 
Do you agree to fulfill the Duty of Obedience? A responsibility to bear the legal responsibility of ensuring that the organization complies with the applicable federal, state and local laws and adheres to its mission.
Do you agree to maintain confidentiality by not disclosing confidential or privileged information?
Do you agree to protect the Chapter's intellectual property?
Thank you submitting your interest to volunteer with the ACMP Midwest Chapter. As a reminder, interest will be reviewed by the Board of Directors and notifications will be sent out by the end of June. For more information please visit our website www.acmpmidwest.org.

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