Advisory Committee Nomination Form

Advisory Committee Nomination Form
Nominations should be submitted two weeks prior to the relevant committee meeting. The committee will review the nomination and make a recommendation to the board for consideration at its next meeting. Nominees should plan to attend the committee meeting at which their application will be considered.
Committee*
Name*

First NameLast Name
Credentials (initials only)*
License or certificate number*
Address*

Address

Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Do you have an investigation or complaint pending on a nursing license or nursing-related certificate or credential in any state?*

YesNo
Are you under current discipline on a nursing license or nursing-related certificate or credential in any state?*

YesNo
Educational preparation, beginning with most recent
Institution*
Degree & Major*
Institution
Degree & Major
Institution
Degree & Major
Professional experience, beginning with most recent
Employer & position/title*
Employer & position/title
Employer & position/title
Nursing specialty*
Select lactation certification(s):*

CLCIBCLCCertified Breastfeeding SpecialistIndigenous Lactation CounselorMilitary Lactation CounselorOther certificationNone. I am applying to be a public member.
Other pertinent activities / Conflicts of Interest
Chemical dependency experience*
Biography*
Resume*

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Advisory Committee Nomination Form

Educational preparation, beginning with most recent

Professional experience, beginning with most recent