Willingness - To - Serve- Form
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 Name________________________________________ Title_______________________________ (as it will appear on the ballot)
Position running for________________________________________________________________ Work Address:______________________________________________________________________
Institution ________________________________________________________________ Email Fax ________________________________________________________________ Street City State Zip Code Home Address: _______________________________________________________________ Street City State Zip Code ________________________________________________________________ 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.
Complete the following information (or attach your resume) Educational Institution(s) and Degree(s) Earned:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Certifications:_______________________________________________________ Current/One Previous Position (Dates, titles, Institutions, City):
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Organizational Activities and Professional Offices Held: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
APIC-NE Philosophy:
[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: Jessica L. Swain, MBA, MLT, CIC 1 Medical Center Drive Lebanon, NH 03766 [email protected]
Relationship
Biographical Information/Signature Name________________________________________ Title_______________________________ (as it will appear on the ballot)
Position running for________________________________________________________________ Work Address:______________________________________________________________________
Institution ________________________________________________________________ Email Fax ________________________________________________________________ Street City State Zip Code Home Address: _______________________________________________________________ Street City State Zip Code ________________________________________________________________ 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.
Complete the following information (or attach your resume) Educational Institution(s) and Degree(s) Earned:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Certifications:_______________________________________________________ Current/One Previous Position (Dates, titles, Institutions, City):
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Organizational Activities and Professional Offices Held: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
APIC-NE Philosophy:
[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: Jessica L. Swain, MBA, MLT, CIC 1 Medical Center Drive Lebanon, NH 03766 [email protected]
Relationship
