Board Seat Nomination

Please complete this form to submit a nomination for an ADA board seat. All fields marked as required must be filled in before submission.

First name

Last name

Email address

Phone number

This nomination is for:

Self

Other

If Other: has nominee consented to serve on the ADA Board of Directors?

Yes

No

Is the nominee a current ADA Member

Yes

No

If the nomination is for other, enter the name of the person submitting this form

Professional background of nominee

Statement of interest of nominee

Is the nominee interested in serving on a committee (you do not need to be on the board of directors to serve on a committee).

Relevant qualifications and experience

(Include any prior board experience, leadership roles, or specialized knowledge.)

Have you previously served on a board?

Yes

No

Previous board experience

Are you available to attend regular board meetings?

Yes, I can commit to regular attendance

I may have occasional conflicts

No, I have significant scheduling constraints

Resume or CV

Please upload your resume or CV. Accepted file types: documents or images.

I confirm that all information provided in this nomination form is accurate and complete to the best of my knowledge.

Signature

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Please sign to confirm your nomination submission.

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