I am interested in running for the office of (indicate 1st, 2nd, and 3rd choice in priority order) :

SECTION 2

It is the considered opinion that this student’s record of performance (academic, clinical, and co-curricular) is satisfactory and that he/she will be able to devote the necessary time and effort to NSANYS responsibilities?  YES NO

If elected, can the student expect support from the Dean/Director for participating in official NSANYS activities that are required for fulfillment of responsibilities?
YES NO(if “NO” please explain why on this text area )

SECTION 3

School and State association activities.  , please list all school and state association activities you have been involved in.  Include any elected positions and/or committees you have served on.

SECTION 4

State your goals for office.  please list three or four goals you wish to accomplish as a member of the NSANYS Board of Directors.

SECTION 5

Consent:

If elected, I promise to serve the NSANYS to the best of my ability.  I am aware of the time and effort to fulfill the responsibilities outlined for the office to which I have been nominated.  To the best of my knowledge, all statements on this application are true. I realize that any false statements, incompleteness, or failure to follow directions on this application may result in my disqualification as a candidate and/or potential NSANYS office holder.

Date

FOR NOMINATING AND ELECTIONS COMMITTEE USE ONLY:

Credentials are in order  YES   NO       

CANDIDATE FOR THE POSITION OF