2021 ISAPN CALL FOR CANDIDATES

1.PLEASE COMPLETE THE INFORMATION BELOW(Required.)

NAME AS IT SHOULD APPEAR ON THE BALLOT:

Credentials:

Address:

City/Town:

State:

ZIP:

Home Phone:

Cell Phone:

Preferred Email:

2.EDUCATION - highest level of education(Required.)

DEGREE

SCHOOL

3.PLEASE INDICATE YOUR APRN SPECIALTY(Required.)

CNM

CNP

CNS

CRNA

4.PLEASE INDICATE YOUR CLINICAL SPECIALTY i.e. primary care, acute care, women's health, etc(Required.)

5.EMPLOYMENT (Required.)

EMPLOYER

PRESENT POSITION

6.I CONSENT TO HAVE MY NAME PLACED ON THE BALLOT FOR THE FOLLOWING POSITIONS.(Required.)

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.)

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 Agreement
2. Code of Ethics for Committee Member Conduct
3. Board of Directors Confidentiality Agreement
4. Conflict of Interest Policy

Completion of the line below serves as the electronic signature of the individual completing this form.

(Required.)

Name:

Date:

2021 ISAPN CALL FOR CANDIDATES - ELECTIONS

MEMBER INFORMATION