Board Candidate Application

Board Candidate Application
Please note you will be asked to upload your curriculum vitae (CV) or resume and current headshot (photo) at the end of this form.

EVERYONE interested in a position on the board must fill out an application. Sitting board members that are interested in another term or new position, must also fill out a new application.
Name*

First NameLast Name
Credentials*
Discipline - please choose all that apply:*

NursingPhysicianOncologyRadiologyVascular AccessRRTPA-CAPRNPharmDOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Please enter a valid phone number.
Email*
example@example.com
Are you a current AVA member?*

YesNoI don't know
What is your Member Number?
What year did you join AVA?
Which board are you interested in applying for? (check all that apply)*

AVA BoardAVA Foundation Board
What position are you applying for or are interested in? (check all that apply)*

President-ElectSecretaryTrasurer-ElectDirector at Large
Are you a member of an AVA Network? If so which one(s)?
Please list any AVA Networks where you have held a leadership position and approximate years the position was held (most recent first)*
Please list any leadership positions/committees you have held with other organizations in the vascular access or related healthcare space and approximate years (most recent first). These organizations may include INS, APIC, nursing, medical, hospitals, etc. (You may also list any leadership positions you've held on non-healthcare boards.)*
Please write a personal biographical statement in the first person (300–400-word limit). You may want to include: What makes you a good candidate for the position and how AVA would benefit from your service? Your personal and professional experiences and accomplishments, education, areas of clinical/management/business expertise, leadership/mentorship experience, outreach ability, etc.*

0/450
Given the above description of the Board of Directors’ strategic focus and culture, what is your vision for the future of AVA and its members? (200-word limit) *

0/250
How did you become involved with AVA and how did your involvement evolve over time?*
Do you possess a professional license in any U.S. State, Territory or Country?*

YesNo
Please list the states and type of licensure held.*
Type N/A if not applicable
Is each license referenced above in good standing?*

YesNoN/A
If no to the above question, please provide a listing of the status. (i.e. California-Suspended, Arizona-Inactive)*
Type N/A if not applicable
Has any action ever been taken by a licensing entity or board against any of the licenses listed above?*
Type N/A if not applicable
Check the boxes below to indicate you have read and understand the follow:*

I have read the position descriptionsI understand the time commitment and are willing to meet those obligationsI have read AVA's Conflict of Interest Policy
Please list any potential conflicts of interest:
Please upload your CV or resume*

Cancelof
Please upload a professional headshot/photo that will be used in communications to the AVA membership.*

Cancelof
Should be Empty: