2025 Southwestern Virginia Chapter Position Interest Form

Southwestern VA Chapter Position Interest and Consent to Serve Form

All submissions must be submitted by 11:59 pm on May 21, 2025. Please note that all information will be shared as submitted with the nominating committee, board, and VNA membership as needed.
Please choose your chapter from the options below.*
Name*

First NameLast Name
Credentials*
Daytime Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer*
Title*
E-mail*
Select one position*
Position Description:

President (2-year term to start 1/1/2026 and conclude on 12/31/2027)
1. Keep the chapter focused on setting and maintaining its goals.
2. Oversee officers and committees and encourage teamwork.
3. Maintain the operations of the chapter.
Relevant Experience/Roles
Please describe your relevant leadership experience in each category below. (75 word maximum per section). Please note that your responses will be shared AS WRITTEN (unedited) along with your headshot/photograph with all VNA members for voting purposes.
VNA/ANA/Chapter Level*

0/75
Professional/Work*

0/75
Community/Civic/Other*

0/75
Candidate Statement
Please submit a statement describing why you are the ideal candidate for the position. (150 word maximum)
Candidate Statement Text*

0/150
Upload Resume/CV*

Upload a File

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Candidate Headshot*

Browse Files

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OPTIONAL: As part of our commitment to ensure representation from diverse individuals and perspectives, we ask our potential candidates for board and nominating committee positions to provide demographic data.
How do you identify your race/ethnicity? You may select more than one.

AsianBlack/AfricanCaucasianMiddle EasternHispanic/LatinoNative AmericanPacific IslanderOther
We realize that the racial/ethnic category you selected may encompass many different nationalities. Please use the space below to provide any additional information.
Certification and Consent to Serve

By clicking the electronic consent box below, I certify that I wish to run for the Virginia Nurses Association position indicated above. I understand the duties and responsibilities involved in this office and, if elected, I agree to serve and abide by the VNA bylaws, board policies and actions, and the ANA Code for Nurses. I understand that checking this box serves as my electronic signature.

I certify my understanding that VNA policy requires that no officer or director of the board shall serve concurrently as an officer or director of a board of another association or body if such participation might result in conflict of interest to VNA or the individual as determined by the board. I also understand that I may be requested to provide the Committee on Nominations with additional information to facilitate the development of the slate of candidates.

Further, I understand that checking the box below serves as my electronic signature and indicates my consent to serve if elected. My signature below further confirms that, in accordance with the above referenced VNA policy, I do not hold membership on a board of directors or other governing body of any other organization which could result in a conflict of interest.

I certify that the information on this form is true and accurate to the best of my knowledge.
Electronic Signature*

I consent.
Should be Empty:

Southwestern VA Chapter Position Interest and Consent to Serve Form