Candidate Statement Form

Please fill out this form completely using the format specified.

Position (If running for more than one position, please fill out one form for each.)

Your name as you would like it to appear on the ballot.

Titles and Certifications (no years)

Education:

School name, degree initials, major. (Example: Stanford University, BS, Human Biology)

Business Practice Name and Your Position:

(Example: North Cumberland Medical Center, Director of Therapies)

Is your current practice owned by a self-referring source?

Yes

Current APTA Washington and APTA Volunteer Activities:

Position, group, start date to present. (Example: Chronic Pain/Opioid Alternative Task Force, Chair, 2016 to present)

Past APTA Washington/APTA Activities:

Position, group, start and end years. (Example: PTWA Education Committee, Chair, 1987-1990)

Other Current Community Service Activities:

Position, organization, start date to present. (Example: Northwest Rotary Club, President, 2015 to present)

Awards

Name of award, full name of organization that gave it to you, year you received it. (Example: Spirit Award, North Manhattan Rotary Club, 2015)

Statement about why you think you will be effective in this position:

(150 words or less please)