APTAMA Nomination Form (2018)
Please complete the following form to be considered for the 2018 APTAMA Slate of candidates for the election. The terms begin Jan 2019. Please complete this nomination form by 9/4/18. The slate will close prior to APTAMA Fall Representative Assembly.

Please forward your current resume / CV via email to aptama@libertysquaregroup.com.
Please also include a current photo / headshot in jpeg.

Email address *
Name (with credentials): *
Your answer
APTAMA District you are in (if you don't know, list the town you use for your APTAMA membership) *
Your answer
Town you vote in (residential address) *
Your answer
Phone
Your answer
APTA Membership number *
Your answer
Expiration of Membership
Your answer
Years of membership
Your answer
Current place of employment
Your answer
Current job title
Your answer
Chapter position you wish to nominate / recommend / consent to:
Central District
North Metro District
Southern Metro District
Southeastern District
Western District
Cardiovascular and Pulmonary SIG
Geriatric SIG
Manual Therapy SIG
Neurology SIG
Pediatric SIG
Private Practice SIG
PTA SIG
Shoulder SIG
Student SIG
List all APTA Activities during the last five (5) years Please Include: District, Chapter, Section & National Levels - Include Resume / CV (emailed separately to tamara@leahymg.com)
Your answer
Any additional information
Your answer
If elected, I consent to serve (please type your name and date as an electronic signature)
Your answer
Thank you. Please forward your current resume / CV via email to aptama@libertysquaregroup.com. Please also include a current photo / headshot in jpeg.
A copy of your responses will be emailed to the address you provided.
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