Willingness - To - Serve- Form
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Willingness - To - Serve- Form Board members are notably essential to carry out the ongoing responsibilities, goals and objectives of APIC-NE. The Board oversees the following activities: Fiscal Responsibilities, Bylaws, Education, Communications, Membership, Program and Nominating Committees. Candidates are recommended by colleagues or volunteer for vacant Board positions. Individuals are elected by the membership and serve on the Board per job description roles. The Board positions begin in January, but individual members may be appointed any time a vacancy exists.
Biographical Information/Signature Title
Name (as it will appear on the ballot)
Position running for WorkAddress: Institution Fax
Email Street
City
State
Zip Code
Street
City
State
Zip Code
Home Address:
Work Phone
Cell Phone
Home Phone
APIC Membership Number:
Signature I have been informed of the duties of the office for which I am a candidate. If elected, I will serve in this office to the best of my abilities.
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Educational Institution(s) and Degree(s) Earned (required):
Current/One Previous Position (Dates, titles, Institutions, City) (required):
Organizational Activities and Professional Offices Held (required):
APIC-NE Philosophy (required): [Please write a brief statement about your philosophy regarding APIC-NE( see sample statements)] (Limit 150 words)
Conflict of interest:
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Are you, or a member of your family involved in any activity that may create a conflict of interest for you in meeting the responsibilities of this office that the Board of Directors should be informed of ? No Yes If yes, please explain
Professional References: Please list names, addresses, telephone numbers and professional relationship below. If you have served on the APIC Board or Committee in the past, please include a name as one of your references.
Name
Address
Phone
THANK YOU! Please return these forms to: Mary Ann Holt. 811 Meadowbrook Rd. Brattleboro, VT 05301 Phone : 802-345-6475 [email protected]
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Relationship
Willingness - To - Serve- Form Board members are notably essential to carry out the ongoing responsibilities, goals and objectives of APIC-NE. The Board oversees the following activities: Fiscal Responsibilities, Bylaws, Education, Communications, Membership, Program and Nominating Committees. Candidates are recommended by colleagues or volunteer for vacant Board positions. Individuals are elected by the membership and serve on the Board per job description roles. The Board positions begin in January, but individual members may be appointed any time a vacancy exists.
Biographical Information/Signature Title
Name (as it will appear on the ballot)
Position running for WorkAddress: Institution Fax
Email Street
City
State
Zip Code
Street
City
State
Zip Code
Home Address:
Work Phone
Cell Phone
Home Phone
APIC Membership Number:
Signature I have been informed of the duties of the office for which I am a candidate. If elected, I will serve in this office to the best of my abilities.
□
□
Educational Institution(s) and Degree(s) Earned (required):
Current/One Previous Position (Dates, titles, Institutions, City) (required):
Organizational Activities and Professional Offices Held (required):
APIC-NE Philosophy (required): [Please write a brief statement about your philosophy regarding APIC-NE( see sample statements)] (Limit 150 words)
Conflict of interest:
□
□
Are you, or a member of your family involved in any activity that may create a conflict of interest for you in meeting the responsibilities of this office that the Board of Directors should be informed of ? No Yes If yes, please explain
Professional References: Please list names, addresses, telephone numbers and professional relationship below. If you have served on the APIC Board or Committee in the past, please include a name as one of your references.
Name
Address
Phone
THANK YOU! Please return these forms to: Mary Ann Holt. 811 Meadowbrook Rd. Brattleboro, VT 05301 Phone : 802-345-6475 [email protected]
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Relationship
