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Consent To Serve

Consent to Serve for IENA Elected Office
I am...
A current member of WSNA and consent to have my name listed for nomination to the following elected office (see below, check one) for the year(s) of
Elected Offices Open for Nomination
- President-Elect –2 years (one as President elect, one as President) (Chair Headquarters Committee during President-elect term.)
- Secretary – 2 years
- Treasurer – 2 years
- Director-at-Large – 2 years
- Director – Educational Representative – 1 year
- Director – General Duty Representative – 1 year
- Director – Nursing Management Administration Representative – 1 year
- Director – Independent Practitioner Representative 1 year
- Director – Community/Public Health Representative – 1 year
- Nominating Committee – 2 years
By consenting to serve as an officer, director, or occupational group representative, I recognize that I will be expected to attend Board meetings on the first Monday of each month, participate on a committee (i.e., legislative reception, legislature day, scholarship and awards, newsletter, bylaws, etc.) and to attend any special meetings that may be called.
Board meetings currently held at 4:30 PM on first Monday of the month.
No Board meetings: July and August
Name as it should appear on the ballot (please print):
NOMINEE DEMOGRAPHICS
I consent to be a nominee for the position(s) specified on this form.
Name
Email
Work phone
Home phone
Home address
Street Address City State / Province / Region ZIP / Postal Code Country
Area of practice
NURSING EDUCATION
School of Nursing
Name of School City State / Province / Region
Received
- Diploma
- Associate Degree
- Baccalaureate
Additional Education:
- MN
- MS
- MA
- EdD
- PhD
Other:
PROFESSIONAL NURSING EXPERIENCE
Present position
Employer
If not presently employed in nursing, please indicate the length of time inactive and the reason, e.g. retirement, etc.
ACTIVITIES IN ANA, WSNA and IENA
Present office(s); be specific according to district, state, and/or national:
Past office(s); be specific according to district, state, and/or national:
State Legislative District:
Congressional District:
Candidate’s statement which may be used in an IENA publication:
Signed:
Date - must be mm/dd/yyyy format
MM slash DD slash YYYY
Mail or email completed form to:
Inland Empire Nurses Association
222 W Mission, Suite 231
Spokane, WA 99201

Questions? Phone 509-328-8288 or
Email: jkaiser.iena@gmail.com
Please submit by: May 15, 2018

ADDRESS

Inland Empire Nurses Association (IENA)
222 West Mission, Suite #231
Spokane, Washington 99201
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CONTACT

Phone: 509-328-8288
E-Mail: admin@IENAnurses.org
We are staffed Monday, Tuesday and Wednesday from 1pm to 6pm.

© 2019 Inland Empire Nurses Association

Designed by Heather Wood

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