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) ofElected Offices Open for NominationPresident-Elect –2 years (one as President elect, one as President) (Chair Headquarters Committee during President-elect term.)Secretary – 2 yearsTreasurer – 2 yearsDirector-at-Large – 2 yearsDirector – Educational Representative – 1 yearDirector – General Duty Representative – 1 yearDirector – Nursing Management Administration Representative – 1 yearDirector – Independent Practitioner Representative 1 yearDirector – Community/Public Health Representative – 1 yearNominating Committee – 2 yearsBy 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.NameEmail 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Area of practiceNURSING EDUCATIONSchool of Nursing Name of School City State / Province / Region ReceivedDiplomaAssociate DegreeBaccalaureateAdditional Education:MNMSMAEdDPhDOther:PROFESSIONAL NURSING EXPERIENCEPresent positionEmployerIf 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:Date - must be mm/dd/yyyy format Date 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