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Nomination Form
Term of Office: 2008-2010

Nominations are being accepted for the offices of Treasurer, Secretary, Chief Delegate and Nominating Committee Member(1)

Instructions: Complete one copy of this form for each nominated individual. If you wish, you may nominate a person for more than one elected position on this form. The completed form(s) must be RECEIVED by the Chapter Office NO LATER THAN NOVEMBER 8, 2008 at 5:00 p.m. There will be no exceptions to this deadline.

Any member in good standing is eligible to nominate someone for office.

Please fill in the following information pertaining to the individual you are nominating:
(The fields with an * are required)

*Nominees Full Name:
Home or Work address:
City:
State:
Zip Code:
Home Phone:
Work Phone:

*The above individual is nominated for election to the following office:


or

The Chapter Office will solicit the consent to serve and biographical information from the person you nominate. The individual must have been an active member for at least two years by the election date and be qualified to execute the duties of the elected positions(s).

 
* Your Name:
*APTA ID#:
*District:
*E-mail
 
Designate in what official capacity you are submitting this form; e.g., elected District Officer, Chapter Committee Chairperson or Chapter Member. If no designation is noted, the Chapter Member capacity will be assumed.

Please complete one of the following:
On Behalf of what Chapter Committee?
Committee Office
OR
On Behalf of what District?
Title of District Office
OR

Individual member: