Committee Nomination Form

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Home > Advisory Committees > Committee Nomination Form

Advanced Practice Advisory Committee
Case Review Advisory Committee
Hemodialysis Technician Advisory Committee
Lactation Care Provider Advisory Committee
Medication Aide Advisory Committee
Nursing Education Advisory Committee
Nursing Practice Advisory Committee
Regional Advisory Committees
Committee Nomination Form

CLICK HERE for information about specific committee requirements, responsibilities, and meeting dates. 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:
Personal and Contact Information
*	Nominee’s name:
*	Nursing license or certificate number:
*	Street address or PO Box:
*	City, state, zip:
*	Contact phone #:
*	Contact email address:
*	Employer:
	Employer address:
	Employer city, state, zip:
*	Do you have an investigation or complaint pending on a nursing license or nursing-related certificate or credential in any state?
*	Are you under current discipline on a nursing license or nursing-related certificate or credential in any state?

Educational Preparation, beginning with most recent
*	Institution
*	Dates Attended: To/From
*	Major
*	Degree

*	Institution
*	Dates Attended: To/From
*	Major
*	Degree

	Institution
	Dates Attended: To/From
	Major
	Degree

Professional Experience, beginning with most recent
*	Inclusive Dates: From/To
*	Title:
*	Employer:

*	Inclusive Dates: From/To
*	Title:
*	Employer:

	Inclusive Dates: From/To
	Title:
	Employer:

Other Pertinent Activities
	Please enter other activity information here:

Chemical Dependency Experience – Required for Diversion Program Regional Advisory Committee only
	Please enter chemical dependency experience information here:

*	Biography (to facilitate candidate review). Maximum 250 words.
*	Upload current resume or CV	Upload a file
ACKNOWLEDGEMENT AND SIGNATURE
*	I acknowledge that my attendance is strongly encouraged during meetings at which my nomination will be considered. I understand that as an advisory committee member my role is to assist the Board of Nursing in the performance of its duties to protect the public and that my active participation is required.	I Agree
*	Signature:
*	Date:

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Educational Preparation, beginning with most recent

Professional Experience, beginning with most recent

Other Pertinent Activities

Chemical Dependency Experience – Required for Diversion Program Regional Advisory Committee only

ACKNOWLEDGEMENT AND SIGNATURE