ANA-ILLINOIS CONSENT TO SERVE - ODD YEAR ELECTION CYCLE

MEMBER INFORMATION

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* 1. PLEASE COMPLETE THE INFORMATION BELOW

Name: *

Credentials:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Home Phone:

Cell Phone: *

Preferred Email: *

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* 2. EDUCATION - highest level of education

DEGREE

SCHOOL

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* 3. EMPLOYMENT

EMPLOYER

PRESENT POSITION

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* 4. I CONSENT TO HAVE MY NAME CONSIDERED FOR NOMINATION TO THE FOLLOWING ELECTED ANA-ILLINOIS OFFICES AND/OR AS A REPRESENTATIVE TO THE ANA MEMBERSHIP ASSEMBLY.

I understand that I cannot be elected to serve as an officer or director if such election or service could result in concurrent membership on the ANA-Illinois Committee on Nominations.

All terms are for 2 years.

PRESIDENT (also serves as ANA Membership Assembly Representative)

SECRETARY

DIRECTOR AT LARGE (2 to be elected)

NOMINATIONS COMMITTEE (2 to be elected)

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* 5. Candidate's Statement: (brief statement regarding why you are seeking the position or what you hope to achieve)

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* 6. Information on this page will be used by the Nominations Committee to prepare ballot. To be placed on ballot, you must complete the consent-to-serve form and submit it by the submission deadline. If your name does not appear on the ballot and you still wish to be a candidate, you may self-declare as a candidate by notifying ANA-Illinois office and completing a consent-to-serve form prior to the stated deadline for self-declared candidates.

If elected to the ANA-Illinois Board of Directors or Nominations Committee it is my obligation to attend meetings and do the work of the position. If I am unable to fulfill this commitment, I will resign.

Upon election, I will receive links to the following forms that must be completed prior to the first board/committee meeting.

1. Volunteer Participation Agreement
2. 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.

Name:

Date: