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* 1. Name

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* 2. Credentials/Designation(s)

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* 3. APTA Member Number

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* 5. Cell Phone Number

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* 6. Address

Consent

Please check one box for each position for which you consent to serve and be slated as a candidate for election. By consenting, you agree that your consent and name may be published as a candidate for an APTA Home Health Academy elected office.

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* 7. Vice President

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* 8. Nominating Committee

Duties of the above positions are described in the Home Health Academy Bylaws and the relevant job description. It is expected that elected Home Health Academy leaders will not be restricted by their employment responsibilities from attending, and be willing to attend, Academy Board and Business meetings when required by their leadership roles. By typing in your name below, you affirm that you meet the eligibility requirements of this office as stated in the Academy's Bylaws.

https://aptahhs.memberclicks.net/assets/Home%20Health%20Section%20Bylaws_February%202021.pdf

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* 9. Full Legal Name

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* 10. Date

Date
Candidate Information & Statement

The following information is collected for the purpose of providing candidate details to Home Health Academy members prior to and during elections. All or portions of the information you provide below may be published in the The Quarterly Report and on the Academy's website. By completing this form, you give consent for APTA Home Health Academy to use names or other information provided in this section to promote voting through social media.

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* 11. Please upload a photo of yourself.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 12. Current Professional Position

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* 13. Education

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* 14. Service Involvement

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* 15. Brief Biographical Statement

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* 16. Candidate Statement

(Max of 250 words) – Use this statement as an opportunity to tell members what you think they need to know about your candidacy (your history with the Section, current involvement, why and how you think your service will benefit the Section, its members, and the profession)

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