Online Nomination Sign-Up Form

The Nominating Committee is looking for persons willing to serve the Neurology Section and specific SIGs within the section. If you are interested in getting involved in a leadership position and would like to run for an office, please complete the form below. If you have questions about any of the positions, please contact one of the members of the Nominating Committee: Lee Dibble at Lee.Dibble@hsc.utah.edu, Elizabeth Rasch at rasche@cc.nih.gov, or Sandra Billinger at sbillinger@kumc.edu.

Please answer all questions listed on the form below. The background information will be included on the ballot so that voters can learn more about the qualifications of each of the candidates. The information provided within each section of the form may vary among candidates; however, the form must be kept to a one-page maximum. For help filling out a nomination form, please see the sample completed nomination form.

After answering all the questions on the form, click the “submit” button. You will receive an e-mail confirmation within 48 hours.

Qualifications: Candidates for elected leadership positions must be members in good standing for a period of at least two years immediately preceding their election. Candidates for committees and other non-elected positions within the Section/SIGs require Neurology Section membership.

* = Required Field

*	I have read the above qualification statement and certify that I am eligible to run and consent to serve in the above stated office.
First Name:	*
Last Name:	*
Organization:	*
Org. Address 1:
Org. Address 2:
City
State:
Zip:
Country
E-mail:	*
Position for which you are nominated
Education
Certifications
Current Practice
Employment
Professional Contributions, for example speaking, teaching, # of peer-review publications, etc.
Professional Awards
Previous Involvement in the APTA, Neurology Section or State Chapter
Why are you running for this position? What experiences would you bring to this position that makes you a strong candidate?