Name *

First Name

Last Name

Preferred Phone *

(###)

###

####

Indicate positions of interest *

(check all that apply)

President-Elect (1 to be elected)

Treasurer (1 to be elected)

Board of Directors (2 to be elected)

Nominating Committee (3 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