ANA-Vermont Consent to Serve Form

ANA-Vermont Consent to Serve Form

4 Carmichael Street Suite 111, #215 Essex Junction, VT 05452
Name

First NameLast Name
Credentials
Certifications
Brief biography (describe yourself)
Past Offices,Committee Chair positions, Memberships at the state or district levels
Present Offices, Committee Chair positions, Committee Memberships at state or local level
Activity in other professional orcommunity related associations
Position Interested
Please explain your interest in this position
Email
example@example.com
Phone Number

Area CodePhone Number
Election Agreement

I agree to the above information as accessible to ANA-Vermont if information is requested. I agree to perform the duties of selected office if elected.
Initial
Should be Empty: