Online Nomination Sign-Up Form

Online Nomination Sign-Up Form

The Nominating Committee is looking for persons willing to serve the Section or specific SIGs. Please answer all questions listed below and submit.  If you have questions about any of these positions, or if you are interested in running for an office in the near future, please contact Kathleen Ganley at kathleen.ganley@nau.edu, Terri Ellis at tellis@bu.edu or Lee Dibble at Lee.Dibble@hsc.utah.edu.

Please answer all questions listed below and submit.  The size of each box can be altered to accommodate varying amounts of information on each topic as this may differ 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.

 

Please answer all questions listed below and submit. 

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?
 

The Section would like to extend a special thanks to all of the partnering organizations that have joined in to make the organization an invaluable resource for information, tools, and support for the population we serve.