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: Sandra Billinger at sbillinger@kumc.edu, Patty Scheets at Patricia.Scheets@gentiva.com, or Judy Burnfield, jburnfield@madonna.org.

The open positions for the upcoming election cycle are list below. Clicking on the position listed will open a new window that describes the duties and requirements for each position.

Board of Directors: Vice-president
Board of Directors: Director of Education
Neurology Section: Nominating Committee Member
Speical Interest Groups: Secretary
Special Interest Groups: Nominating Committee

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.

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:	*
City
State:
Country
E-mail:	*
Position for which you are nominated
Degrees Earned (Include University, degree earned, and year Example: University of Illinois, BS, 2001)
List Relevant Certifications (Certification and years held Example: NCS, 2002-2008)
Primary Area of Practice
Clinical /Research/Teaching Expertise (Example: NCS 2009, Neurorehabilitation curriculum)
Employment History (List by employer, title, and years worked Example: Acne Rehab Inc. Director of Rehab. 2002 - 2007)
Professional Contributions (Speaking, teaching, # of peer-review publications)
Professional Awards (Example: Outstanding Staff Therapist, 2005)
Previous Involvement in the APTA, Neurology Section or State Chapter (Example: Neurology Section Nominating Committee, 2010)
Personal Statement (Briefly explain why your are running for this position)