What would you like to do?
Submit Nomination for Governor Appointed Member
Apply to Become a Committee Member
What would you like to do?
Submit Nomination for Governor Appointed Member
Apply to Become a Committee Member
Information About You:
Name
*
First Name
Last Name
Email Address
*
example@example.com
State
*
ZIP Code
*
Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Member Information:
Name of Organization
*
Job Title
Credentials
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website
*
Fax #
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Member Information:
Why are you nominating yourself to be a Governor Appointed Committee Member?
*
Résumé/CV Upload
*
Browse Files
Drag and drop files here
Choose a file
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Committee Selection
Review the committee descriptions provided on this page before making your selection below.
Indicate the committee(s) you are interested in joining:
*
Well-Woman/Black Maternal Health Committee
Social Determinants of Health Committee
Data Committee
Interest in the DHMIC Work Section
Please share your interest in the DHMIC work.
Share your personal interests when it comes to advocacy work in helping the maternal and child health population.
*
Do you have an area of expertise that you will bring to the table?
*
Motivation and Professional Contribution Section
Please share why you want to be a DHMIC member and how your expertise would contribute to the committee.
Why do you want to be a DHMIC member?
*
What is your area of expertise and how would you characterize it?
*
Organization Affiliations and Transparency Section
Please share your lived experience and/or connection to this work.
List your past, current, and future organization affiliations.
*
List any potential conflict of interest.
*
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