2021 ISAPN CALL FOR CANDIDATES - ELECTIONS MEMBER INFORMATION Question Title * 1. PLEASE COMPLETE THE INFORMATION BELOW NAME AS IT SHOULD APPEAR ON THE BALLOT: Credentials: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Home Phone: Cell Phone: Preferred Email: Question Title * 2. EDUCATION - highest level of education DEGREE SCHOOL Question Title * 3. PLEASE INDICATE YOUR APRN SPECIALTY CNM CNP CNS CRNA Question Title * 4. PLEASE INDICATE YOUR CLINICAL SPECIALTY i.e. primary care, acute care, women's health, etc Question Title * 5. EMPLOYMENT EMPLOYER PRESENT POSITION Question Title * 6. I CONSENT TO HAVE MY NAME PLACED ON THE BALLOT FOR THE FOLLOWING POSITIONS. VICE PRESIDENT TREASURER PROGRAM COMMITTEE CHAIR CNM REPRESENTATIVE CNP REPRESENTATIVE NORTHWEST (NW) REGION CHAIR NORTHEAST/SOUTH (NE/S) REGION CHAIR WEST CENTRAL (EC) REGION CHAIR Question Title * 7. Candidate's Statement: (brief statement regarding why you are seeking the position or what you hope to achieve. This will be the statement used on the ballot and in all notices to the membership about the slate.) Question Title * 8. Information within this form will be used by the Nominations Committee to prepare the ballot. To be placed on the ballot, you must complete the consent-to-serve form by the submission deadline. * PLEASE PLAN TO ATTEND THE ANNUAL MEETING VIRTUALLY ON OCTOBER 22ND WHERE ELECTION RESULTS ARE ANNOUNCED. PLEASE SUBMIT A HEADSHOT TO SUSAN SWART syswart@isapn.com BY JULY 15, 2021 Candidate information will appear on www.isapn.org. Elections will be conducted electronically. Voting will be open September 9, 2021 and close at 5 pm on September 23, 2021. Results will be announced at the Annual Business meeting during the ISAPN Midwest Conference.IMPORTANT PLEASE READ THOROUGHLY: Upon election, I will receive links to the following forms that must be completed prior to the board orientation - date to be determined. 1. Volunteer Participation Agreement2. Code of Ethics for Committee Member Conduct3. Board of Directors Confidentiality Agreement4. Conflict of Interest PolicyCompletion of the line below serves as the electronic signature of the individual completing this form. Name: Date: Done