2019-2021 International Officer Candidate Information Form

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Submitted By *

First & Last Name

Name at time of initiation, if different:

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Submitter Email *

S/P/N *

State/Province/Nation

Chapter Name *

Ex: Alpha, Gamma, etc.

Candidate for the office of:

Year Initiated:

Chapter initiated into:

S/P/N and Chapter

Currently a member of:

S/P/N and Chapter

I. International Conventions Attended (year only, beginning with the most recent:

II. Regional Conferences Attended (year only, beginning with the most recent:

III. Term of office as chapter president:

Term of office as S/P/N president:

IV. Leadership Experience (For each level, list accurate information in chronological order, including dates, beginning with the most recent. The Candidate Qualifications Committee will verify information.):

A. International Level, 1. International Offices:

2. International Level, International Standing Committee (Those that report at the Convention, for example, Educational Symposium Committee.):

3. International Committees served as part of of your International Chapter Office or IEB work, such as Minutes Review Commitee:

4. Service at the International level, such as Sergeant-at-Arms at Convention, presenting at the Educational Symposium and singing in the International Chorus during Convention:

B. Regional Level:

C. State/Provincial/ National Level:

V. Non-AlphaDeltaKappa Organizations --Offices and/or Honors -- (List no more than FIVE organizations of which you are a member AND offices and/or honors you have received in the last 12 years. You may list service as an officer, committee chairman or member of the executive board, if appropriate. NOTE: A limit of five non-Alpha Delta Kappa activities will be listed in the KAPPAN.

Compose an essay (in paragraph form, no poems or acrostics) of no more than 100 words to answer the following question: (The essay will appear in the April 2019 KAPPAN) "What do you see as a priority for Alpha Delta Kappa's future?" How will you work to advance that priority?" The first 100 words will be published. ("a," "and," & "the" are counted as words).

0/100

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By submitting your photo, you are giving Alpha Delta Kappa permission to use your photo in its publications.

*A candidate is not permitted to change the office for which she applied.

Candidates must submit their application on or before November 1, 2018 to Ginger Modla, Chairman, International Candidate Qualifications Committee, at gbmodla@gmail.com. Applications must be accompanied by the Online Candidate’s Form with your S/P/N president’s signature and with a photo to the International Candidate Qualifications Committee. You will receive confirmation by e-mail.