2022 E-board/Committee Inquiry Form

Name

First Name

Last Name

Phone

(###)

###

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Are you a chapter member?

*Your dues must be current in order to participate in the election process

Membership Type

Nominee for Executive Board positions must be a Licensed Professional RN

Are you self-nominating or nominating a chapter member

Name of Member Nominated

If your nominating an active member for office, please enter their name below