ANVC Candidate Nomination Application - 2021

Nomination applications must be submitted electronically
The information provided in the application will be reproduced as presented for the ballot
If you have questions, please email nominating-committee@anvc.org

Question Title

* 1. Position for which you are submitting for:

ANVC Board as Member-at-Large

Leadership Development Committee

Question Title

* 2. Contact Information

Name

Company

Address

City/Town

State and Zip Code

Time Zone (Interviews will be held via telephone)

Email Address

Home Phone Number

Work Phone Number

Cell Phone Number

Question Title

* 3. Are you a current ANVC member?

Yes

Question Title

* 4. Candidate Statements

Please upload your written statement of 250 words or less addressing the following issue: Describe your vision for neurovascular clinical practice and the role of the ANVC.

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

Choose File

Question Title

* 5. Please upload your full CV that highlights your Employment, Education, Credentials, Awards, etc.

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

Choose File

Question Title

* 6. Please upload a photo in .jpg format

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

Choose File

Question Title

* 7. I will provide the ANVC with references using the ANVC Candidate Reference Form.

Yes

Question Title

* 8. I have read and agree to abide by ANVC's Conflict of Interest and Confidentiality Policy if elected to the Board or selected for a Committee position and agree to disclose all conflicts of interest. A copy of the Conflict of Interest Policy can be found on the ANVC website: www.anvc.org/COIpolicy.

Yes

Question Title

* 9. CONFLICT OF INTEREST DISCLOSURE FORM

No, I have no relevant personal, financial and/or "competitive" relationships

Yes, I do have personal, financial and/or "competitive" relationships (If yes, proceed to next question)