Public Health and Community Nutrition DPG Nomination Form for the 2022 Ballot
Please select the position for which you would like to be nominated.
PHCN DPG Chair-Elect (3 year term)
PHCN DPG Nominating Committee Chair-Elect (2 year term)
PHCN DPG Secretary (2 year term)
Name
First Name
Last Name
Credentials
Email
example@example.com
Academy ID Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone Number
Please enter a valid phone number.
Home or Cell Phone Number
Please enter a valid phone number.
Current Employment Position
Employment History (begin with most recent)
Education (begin with most recent)
Please list Computer & any Electronic Media Skills
Please list Academy-PHCN DPG and Public Health/Community Nutrition Related Organizational Activities (begin with most recent)
Please list Leadership Positions Held (begin with most recent)
Please list any other Pertinent Professional Activities
Personal Statement: Tell us why you are interested in running for this position in 100 words or less
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