Please select up to three committees for which you would like to nominate an individual or yourself. Please rank the committees selected in order of preference. Please be sure to review the committee descriptions before making a nomination to learn about the work and responsibilities expected of the committee members. For a list of committee descriptions, see this page. In an effort to create diverse and widespread representation, each committee may be limited to one participant per state and company. All 2022/2023 Committee Appointments will be for a two-year term.

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* 1. Nominator Information (If different from nominee)

All questions from this point forward are about the nominee

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* 2. Nominee Information

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* 3. Nominee Race

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* 4. Nominee Ethnicity

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* 5. Nominee Gender

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* 6. The nominee is aware of this nomination? (If other than self-nomination)

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* 7. Company Type (Select One)

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* 8. AHCA/NCAL Member

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* 9. Long Term Care Facility Type (check all that apply)

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* 10. Ownership Types: Please describe the type of facility(ies) for which the nominee works and/or owns.

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* 11. For profit/Not for profit status

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* 12. Does the nominee own skilled nursing or assisted living centers?

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* 14. The nominee has read the committee descriptions, understands the expectations, and is willing to serve on one of the above chosen committees if appointed.

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