2024 Public Member Application

Biographical Form for Appointment as Public Member NCHEC Board of Commissioner (3-year term)

The National Commission for Health Education Credentialing, Inc. (NCHEC) has a mission to enhance the professional practice of Health Education by promoting and sustaining a credentialed body of Health Education Specialists. To meet this mission, NCHEC certifies health education specialists, promotes professional development, and strengthens professional preparation and practice.
Form Instructions

Complete the form in full. State information clearly and succinctly as this will be the only biographical information reviewed for appointment. No attachments will be accepted. DO NOT USE ABBREVIATIONS. All personal information will be confidential within NCHEC. SIGNATURE IS REQUIRED. Nominations should be mailed to NCHEC, 1541 Alta Drive, Suite 303, Whitehall, PA, 18052, faxed to 1-800-813-0727, or scanned and emailed to nchec@nchec.org by September 1, 2023.
Name*

PrefixFirst NameLast NameSuffix
Please select the gender you identify as
If your gender is not listed above, please write it in
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Business Phone Number*

Area CodePhone Number
Home Email*
example@example.com
Work Email*
example@example.com
Preferred Mailing Address*

HomeWork
EDUCATION (Highest Degree Earned)*
EDUCATION (additional degree earned, if applicable)
EDUCATION (additional degree earned, if applicable)
Other Academic Achievements and Honors (continuing education and certification).
EMPLOYMENT/VOLUNTEER ACTIVITIES*
Description of present employment position, including work setting and responsibilities.*
Past Significant Employment or Volunteer Positions Held
Past Significant Employment or Volunteer Positions Held
If appointed, how would you contribute to the position? Why should you be appointed?*
Other information you would like to provide.
By checking the box below, I attest that neither my immediate family nor I is a(n):
- current or previous member of the health education profession
- Certified Health Education Specialist (CHES®) or Master Certified Health Education Specialist (MCHES®) credential holder
- employer or an employee of individuals in the health education profession
- employee of an individual certified by NCHEC or of any health education organization
- employee of any certification organization
- recipient of monies from the health education profession
- previous worker, contractor, and/or provider of services to NCHEC within the past five years
If appointed, I agree to serve.*
Signature*

Clear
Date of Signature*

MonthDayYear
IMPORTANT

NCHEC’s Board of Commissioners must avoid ethical, legal, financial and other conflicts of interest, and must sign a conflict-of-interest statement and ensure that their activities and interests do not conflict with their obligations to the NCHEC or its welfare. Any questions regarding potential conflicts of interest should be directed to the Deputy Executive Director. Melissa Opp, MPH, MCHES®, ICE-CCP; Attn: NCHEC Deputy Executive Director, 1541 Alta Drive, Suite 303, Whitehall, PA 18052 Phone: 888-624-3248 Fax: 800-813-0727 or emailed to nchec@nchec.org
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Biographical Form for Appointment as Public Member NCHEC Board of Commissioner (3-year term)

Form Instructions

IMPORTANT