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* 1. Contact Information

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* 2. Requested Committee (List in Order of Preference)

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* 3. Please check the box if you are interested in a Chair position. **Please ensure that you have read and understand the requirements associated with the Chair role**

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* 4. Relevant educational background/certifications/work experience:

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* 5. Statement of your job responsibilities relating to committee(s) named:

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* 6. Special contributions you can make or strengths you can bring to the work of the named committee(s):

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* 7. Why do you want to serve on this/these committee(s)?

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* 8. Do you have the support and approval of your organization's management to meet the commitments and requirements of a PSA committee? 

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* 9. Supervisor Contact Information

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* 10. Have you read the Committee charter as outlined by PSA?

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