NBCRNA Board of Directors Emerging Leader Fellow Application (2026) Survey

1.Your name (please include first name, middle initial, last name and your credentials):

2.I am currently an active member of the AANA.

Yes

3.If selected for the Emerging Leader Fellowship, I agree to become an active member of the AANA, if I am not currently a member.

Yes

4.Certification: The fellowship is intended for certified nurse anesthetists initially certified in the past 2 to 5 years. In what year were you initially certified as a nurse anesthetist?

5.Contact Information: Home

Street Address:

City, State, Zip:

Cell Phone:

Email (all applicants must have an email address and the ability to access it daily):

6.Contact Information: Business

Current Employer:

Job Title:

Business address:

Business Phone:

Business Email:

7.Why are you interested in the Emerging Leader Fellowship? (up to 250 words)

8.What are your leadership goals in the short term (over the next 5 years) and long term? (up to 250 words)

9.Describe your current employment, including major clinical, teaching and practice area; field/place of employment; and responsibilities. (up to 250 words)

10.Education and Credentials. List your educational history. (Please begin with highest degree/credential earned.)

Degree/Diploma - Area of Study - Year Obtained - Educational Institution

11.Work History. List your work practice/employment history. (Please begin with the most recent position.)

Employer - Job Title - Years - Responsibilities

12.Have you ever been asked to leave or resign from a professional nursing position, lost your privileges, or had disciplinary action taken against your license?

Yes

If yes, please explain.

13.Professional Memberships, Affiliations, Elected Positions, and Leadership Experience. List elected or appointed positions and/or involvement on boards or committees at the community, state or national level, or at educational institutions.

14.Have you participated on any NBCRNA committees?

Yes

If yes, please specify.

15.Attestations (please answer yes or no):

Would serving on the Board cause a personal or professional conflict of interest?

I can make a substantial time commitment to be an active contributor to the Board.

I am available to attend the Board meetings on October 2-3, 2026; February 2027; June 2027 and October 2027 (exact dates to be determined).

I can attend a mandatory two-day Board orientation in Chicago, IL, early-August 2026.

Are you a director or employee of any organization that may have a direct or indirect conflict with the NBCRNA?

If selected for the Emerging Leader Fellowship, I agree to:
- Attend all meetings and complete all assignments as required by the NBCRNA; and
- Uphold my fiduciary responsibility to the NBCRNA.

I understand in order to be considered, the application form, curriculum vitae, and one confidential letter of recommendation must be submitted by the deadline of April 1, 2026.

16.Signature: By printing your name and date, you will be considered to have signed this form.

17.Letter of Recommendation: One confidential letter of recommendation from someone who would support your selection must be received on or before April 1, 2026, via email or post to:
Email: nominations@nbcrna.com

NBCRNA Nominations Committee
8725 W. Higgins Road, Suite 525
Chicago, IL 60031

Who will be providing your letter of recommendation? (include name, phone, business/institution and email address)
*Note: Current NBCRNA Board of Directors and NBCRNA staff are not eligible to write a letter of recommendation.

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NBCRNA Board of Directors Emerging Leader Fellow Application (2026)

Emerging Leader Fellowship Application