NAHN Intent To Run Form 2019 Dear NAHN member – Thanks so much for your recent participation in the NAHN Nominating Committee webinar and for taking the next step to becoming a candidate for office. Please prepare a photograph that you’d like to use for our candidate announcement. Staff will be following up with all candidates who complete the intention to run form to request your photograph. Question Title * 1. Personal contact information of nominee. Name * Chapter * Address * Address 2 City/Town * State/Province * -- 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/Postal Code * Email Address * Phone Number * Question Title * 2. Provide the following information about your employer. Employer Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Work Email Address * Work Phone Number * Question Title * 3. Additional nominee information. Credentials RN/LPN/LVN License # NAHN Chapter Position/Title Question Title * 4. Please indicate the position you are seeking. (Only one position per submission). Treasurer Secretary Board Member Two-Year Position (three positions) Question Title * 5. Please describe your NAHN experience and other qualifications for seeking this office. Question Title * 6. Please provide your platform statement (150 words maximum) Question Title * 7. By entering your name as a digital signature in the space provided below you are confirming that you are a current member of NAHN and that the information you provided is true and up to date. Done