Consent To Serve Consent to Serve for IENA Elected OfficeI 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 AugustName 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 phoneHome phoneHome address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Area of practice NURSING EDUCATIONSchool of Nursing Name of School City State / Province / Region Received Diploma Associate Degree Baccalaureate Additional Education: MN MS MA EdD PhD Other: PROFESSIONAL NURSING EXPERIENCEPresent 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 IENAPresent 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: Reset signature Signature locked. Reset to sign again Date 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
