2025 - 2026 NMA Nomination Application

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* 1. Demographics

Name

Address

City/Town

State/Province

ZIP/Postal Code

Age

Mobile Phone

Office Number

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* 2. Medical School and Location

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* 3. Medical School Graduation Year

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* 4. Specialty

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* 5. Are you a current dues paid NMA member?

Yes

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* 6. Please indicate which years you have been a dues paid NMA member

2023

2022

2021

2020

2019

None of the above

If you have not been a member in any of these years, please explain

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* 7. Do you currently hold an unexpired and unencumbered license to practice medicine?

Yes

If you have a current valid license, please indicate your primary state and license number

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* 8. Do you currently hold or have previously held licenses in any other state?

Yes

If yes, please indicate state and license number

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* 9. Has your license to practice medicine ever been revoked, limited or denied?

Yes

If yes, please explain

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* 10. Please indicate the office for which you wish to be a candidate

President Elect

Speaker, House of Delegates

Vice-Speaker, House of Delegates

Secretary, House of Delegates

Treasurer

Trustee Region I

Trustee Region II

Trustee Region IV

Trustee Region V

Trustee Region VI

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* 11. What NMA Region are you affliated with?

Region I

Region II

Region III

Region IV

Region V

Region VI

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* 12. What local/state society are affliated with?

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* 13. Please upload Interest statement

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* 14. Upload current Curriculum Vitae or Resume

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* 15. Upload copy of unexpired and unencumbered medical license

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* 16. 1-2 minute personal introductory video. Please list the link, to your video, below. If you do not have a video link, you may email your file to lwhite@nmanet.org

2025 - 2026 NMA Nomination Application

Question Title

* 1. Demographics

Question Title

* 2. Medical School and Location

Question Title

* 3. Medical School Graduation Year

Question Title

* 4. Specialty

Question Title

* 5. Are you a current dues paid NMA member?

Question Title

* 6. Please indicate which years you have been a dues paid NMA member

Question Title

* 7. Do you currently hold an unexpired and unencumbered license to practice medicine?

Question Title

* 8. Do you currently hold or have previously held licenses in any other state?

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* 9. Has your license to practice medicine ever been revoked, limited or denied?

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* 10. Please indicate the office for which you wish to be a candidate

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* 11. What NMA Region are you affliated with?

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* 12. What local/state society are affliated with?

Question Title

* 13. Please upload Interest statement

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* 14. Upload current Curriculum Vitae or Resume

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* 15. Upload copy of unexpired and unencumbered medical license

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* 16. 1-2 minute personal introductory video. Please list the link, to your video, below. If you do not have a video link, you may email your file to lwhite@nmanet.org

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* 17. Current Headshot

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* 18. Regional Chair endorsement letter