KSRC BOD Nomination

KSRC Elected Official Nomination Form

* Indicates required field

Name *

First

Last

Email *

Phone # *

Home Address *

City *

State *

Zip Code *

County of Residence *

Place of employement *

Job Title *

AARC # *

KBRC License # *

For District Reps: Please Specifiy which District *

Please answer the following questions below

1. What previous experience do you have (in the Society, leadership and/or practice experience)? *

2. What interests you about participating in the KSRC at a leadership level? *

3. How have you been involved with the AARC/KSRC or other AARC affiliates (e.g. activities, committees, etc.)? *

I am willing to accept the responsibility of the office for which I have been nominated, if elected to that office.

Please Type your Intitials *

Date *

Submit