I am nominating *

Myself

Someone Else

Name *

First Name

Last Name

Preferred Phone *

(###)

###

####

Indicate positions of interest *

(check all that apply)

Secretary (1 to be elected)

Board of Directors (2 to be elected)

Nominating Committee (2 to be elected)

President-Elect (1 to be elected)

Have you previously served on the eChapter Board of Directors? *

Yes

No

Have you previously served on an eChapter committee? *

Yes

No

Have you attended a eChapter educational webinar? *

Yes

No

Attestation *

I have reviewed the roles/responsibilities in the eChapter Operating Policies on the eChapter Website ... and am willing to fulfill them

Yes

No

Signature *

I confirm that the submission of this information is representative of my electronic signature

Yes

No