PACB 2022 Nominations for Board Member and Ethics Committee MembersPlease enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailPhone *Regarding the Board Certified Patient Advocate Credential *I am a BCPA in good standingMy BCPA recently expiredI am planning to sit for the examI do not plan to sit for the examFor which position are you interested in applying? *Board of DirectorsEthics CommitteeEitherHow many hours per week would you be able to dedicate? *3 hour or less3 to 5 hours5 to 10 hoursBriefly describe why you would like to join PACB leadership either as a director or member of the Ethics Committee? *What would you like to gain from participation on the Board, e.g., what types of experiences, skills to develop, interests to cultivate, etc.? *Briefly describe your current role in Patient and Health Advocacy. *Please list your current organizational affiliations (names of the organizations and your role(s). *Please upload a current Bio, Resume or CV Click or drag files to this area to upload. You can upload up to 3 files. Submit