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2025 - 2026 NMA Nomination Application
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1.
Demographics
(Required.)
Name
Email
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Age
Mobile Phone
Office Number
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2.
Medical School and Location
(Required.)
*
3.
Medical School Graduation Year
(Required.)
*
4.
Specialty
(Required.)
*
5.
Are you a current dues paid NMA member?
(Required.)
Yes
No
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6.
Please indicate which years you have been a dues paid NMA member
(Required.)
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?
(Required.)
Yes
No
If you have a current valid license, please indicate your primary state and license number
*
8.
Do you currently hold or have previously held licenses in any other state?
(Required.)
Yes
No
If yes, please indicate state and license number
*
9.
Has your license to practice medicine ever been revoked, limited or denied?
(Required.)
Yes
No
If yes, please explain
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10.
Please indicate the office for which you wish to be a candidate
(Required.)
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?
(Required.)
Region I
Region II
Region III
Region IV
Region V
Region VI
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12.
What local/state society are affliated with?
(Required.)
*
13.
Please upload Interest statement
(Required.)
Maximum Length 1 page double spaced
Choose File
No file chosen
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14.
Upload current Curriculum Vitae or Resume
(Required.)
Choose File
No file chosen
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15.
Upload copy of unexpired and unencumbered medical license
(Required.)
Choose File
No file chosen
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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
(Required.)
*
17.
Current Headshot
(Required.)
Choose File
No file chosen
*
18.
Regional Chair endorsement letter
(Required.)
Letter should verify that you have been a dues paying member of state or local for 3 previous years
Choose File
No file chosen
