MCNP Director Nomination Submission

MCNP Director Nomination Submission

(Please note you have the option to SAVE your nomination form
and edit/complete prior to submitting.)

Name:*

First NameLast Name

Email:*

example@example.com

Mobile Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Home Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Employer:*

Work Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Title:*

Professional Credentials:*

Position(s) you are Interested in:*

TreasurerRegion III Director (North Shore & Merrimack Valley)Director of Diversity, Equity & InclusionDirector at Large

What do you see as some of the biggest challenges facing NPs in Massachusetts and how do you think MCNP should address these issues to support our members and the patients they serve?*

Describe any professional and leadership skills that have prepared you to serve as an MCNP Director.*

If elected, how do you envision your role in supporting the work of the MCNP and our mission to advance NP practice by means of Leadership, Education, Advocacy, and the Delivery of exceptional care?*

Please upload a copy of your CV.*

Acknowledgements:*

I have read the description(s) for the position(s) I am seeking and understand the roles and responsibilities of the position(s). (See link below.)I have read the MCNP Board Member Conflict of Interest Policy, understand I will be asked about potential conflicts of interest during the vetting process and agree to sign a conflict of interest disclosure if elected. (See link below.)I am willing and able to provide a personal and/or professional reference on request.

Board of Director Roles & Responsibilities

MCNP Conflict of Interest Policy

Signature:

Date:

Thank you! A member of the Nominations Committee will be in contact to discuss next steps once your submission has been reviewed.