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:

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

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

Contact

Events

NOMINEE DEMOGRAPHICS

NURSING EDUCATION

PROFESSIONAL NURSING EXPERIENCE

ACTIVITIES IN ANA, WSNA and IENA

ADDRESS

CONTACT