PACB 2022 Nominations for Board Member and Ethics Committee Members

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Email

Confirm Email

Phone *

Regarding the Board Certified Patient Advocate Credential *

• I am a BCPA in good standing
• My BCPA recently expired
• I am planning to sit for the exam
• I do not plan to sit for the exam

For which position are you interested in applying? *

• Board of Directors
• Ethics Committee
• Either

How many hours per week would you be able to dedicate? *

• 3 hour or less
• 3 to 5 hours
• 5 to 10 hours

Briefly 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.

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