2024 Nomination Form for Elective Office Candidate Information This information is used by the Pennsylvania Chapter Committee on Nominations and Leadership Identification (CCNLI) to make nominations for elective chapter positions, for chapter committees and task forces. To be considered for an elected position, please provide your resume and cover letter which addresses your qualifications for nomination (i.e. strengths/skills that will move NASW-PA forward). Submissions are due by February 15th. Question Title * 1. Nominee Contact Information Preferred Name (first and last) 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 Cell Phone Number Question Title * 2. At what email address would you like to be contacted? Question Title * 3. Credentials Question Title * 4. What are your preferred pronouns? Question Title * 5. You must be a member of NASW Pennsylvania Chapter to run for office. Are you currently a member of the Chapter? If not a current member, do you commit to join? Yes, I am a member of NASW-PA I am not currently a member but I commit to joining in order to run for office. Comments: Question Title * 6. License Number (if applicable) Question Title * 7. Students - University Question Title * 8. Students - Degree Sought Question Title * 9. Students - Graduation Date Question Title * 10. Please check positions that you are willing to be nominated for. Note that to run for Division Chair or Rep you must be a member of that division. Refer to the division map at www.nasw-pa.org/BOD. You may run for only one position at a time, with the exception of delegate to Delegate Assembly. Candidates may run for any other office and also run as a delegate. First Vice President Member-at-Large North Central Division Chair Southeast Division Representative Southwest Division Chair Southwest Division Representative West Central Division Chair BSW Student Representative MSW Student Representative Delegate to Delegate Assembly (7 openings) Member of Chapter Committee on Nominations and Leadership Identification (3 openings) Question Title * 11. If we are unable to slate you for the selected position(s), would you be willing to be slated for any other position? Yes No If "yes" please specify which position(s) Question Title * 12. Have you or do you have pending: Adjudication for unethical practice Licensure certificate disciplinary prodeedings Neither of the above If "yes" to either, please explain and provide dates Next