ACNA 2019 Call for Nominations

Nominations Application and Consent to Serve

Nominations are being accepted to fill five (5) open Member at Large positions on the ACNA Board of Directors. Terms for these positions will be two years, beginning January 1, 2020 through December 31, 2021.

Regular and Retired members of ACNA in good standing who have been members for a minimum of one (1) year at the time of application and have participated on at least one (1) other ACNA Committee are eligible to run for Board of Director positions.

Please complete the the information below and submit. To complete the nomination process, you will be returned to the ACNA website where there is a link to submit your CV and photo (headshot) to ACNA Headquarters.

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* 1. Candidate Information:

Name and Credentials (as it should appear on the ballot):

Current Position:

Current Employer:

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Candidate's Campaign Statement (500 words, including your career, committee service (for ACNA or other organizations), leadership background and your vision for the organization):

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* 3. How long have you been practicing as a nurse?

1-5 Years

6-10 Years

11-20 Years

21-30 Years

30+ Years

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* 4. Please upload your CV. Only PDF, DOC, DOCX, PNG, JPG, JPEG, GIF files are supported.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 5. Please upload a high resolution headshot of yourself. PNG, JPG, or JPEG only.

JPEG, JPG, PNG file types only.

Choose File

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* 6. What is your highest level of education?

Licensed Practical Nurse (LPN)

Associate Degree (ADN)

Bachelor's Degree (BSN)

Master's Degree (MSN)--please specify degree specialty below

Doctoral Degree (PhD, EdD, DNP, DNS/DNSc)--please specify degree specialty below

Master's or Doctoral Degree Specialty

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* 7. In which healthcare environment do you currently work? (Select all that apply)

Acute Care

Long Term Care

Education

Primary Care

Rehabilitation

Community-Based Care

Other (please specify)

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* 8. I consent to have my name and photo made public on the ACNA website.

Yes

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* 9. I have reviewed the ACNA 2019 Bylaws

Yes

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* 10. I have reviewed the ACNA Conflict of Interest Policy

Yes

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* 11. If elected, I agree to service ACNA with dedication and timeliness. I understand that I will be asked to contribute in any capacity as needed or appointed by the President of ACNA.

Yes

By completing this form, you are authorizing ACNA Headquarters to submit your name to the ACNA Nominations Committee for consideration as a candidate for office. Notification of official slate of candidates will be sent to the ACNA membership in October.