*1.Nominee's Name(Required.)

*2.Nominee's Email(Required.)

*3.Nominee's Organization(Required.)

*4.Nominee's Title or Role(Required.)

*5.Which of the following competencies would this nominee bring to the CHA board? Select all that apply.(Required.)

Experience in Church relationships

Experience with communications, marketing, and public relations (including media relations)

Experience with managed care, health care payment models, and/or population health

None of the above

*6.Please provide additional comments about this nominee and the competencies that he/she would bring to the CHA board:(Required.)

*7.Please be sure to advise the person that you are nominating him or her for the CHA board.  Have you had the opportunity to do this yet?(Required.)

Yes

No

*8.Your Name(Required.)

*9.Your Email(Required.)