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House of Delegates Nomination Form
DEADLINE: December 15, 2008

Nomination Form and NYPTA Consent to Serve Form for Delegates to APTA's 2010 House of Delegates, June 14 - 16, 2010, in Boston, MA

Instructions: Individuals wishing to become Delegates to the APTA House of Delegates must submit their own Nomination Forms. Please fill in the form below completely and click on the submit button. The completed form must be RECEIVED in the Chapter Office by December 15, 2008 at 5:00 p.m.. There will be no exceptions to this deadline.

Qualifications: Only active members who have been APTA members in good standing for two years immediately preceding the annual meeting of the House of Delegates for which they are elected may serve as Chapter Delegates.

Please fill in the following information pertaining to the Nominee (* required information):

* Nominee's Full Name:
* Address:
* City:
* State:
* Zip Code:
* Home Phone:
* Work Phone:
* E-mail:
* Current District Affiliation:
* Date of Membership in Chapter:

 

Please list specific Chapter, District or National Association Activities (offices, committees, etc.) in which you have been involved. Please include dates and be specific. The information you provide is used by the Delegate Assembly to evaluate candidates.

* Chapter:

 

* District:

 

* National:

 

The conditions below are mandatory pre-Delegate activities required for Delegates to the House of Delegates. Please check your consent adjacent to the statements:

 

IF ELECTED, I WILL ATTEND DISTRICT MEETINGS WHOSE PRIMARY PURPOSE IS TO DISCUSS ISSUES RELATIVE TO THE DELEGATE ASSEMBLY OR HOUSE OF DELEGATES MEETINGS.

IF ELECTED, I WILL ATTEND THE DELEGATE ASSEMBLY HELD PRIOR TO THE HOUSE OF DELEGATES MEETING FOR WHICH I AM ELECTED.

 
* Date: