Name of Nominee
*
First Name
Last Name
Degree(s)
*
MD
DO
PhD
MPH
Other
Email Address
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Employer
*
City
*
Positions
Please select the position you would like to be considered for on the WACEP Board additionally you may also select to be considered for a WEMPAC Board position.
WACEP Board Position
*
President-Elect
Treasurer/ Secretary
Director at Large (3 open positions)
Councillor to ACEP (4 open positions)
WEMPAC Board Position
Director at Large
Candidate Statement
*
Please limit to 250 words
Submit Nomination
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