AMERICAN PHYSICAL THERAPY ASSOCIATION

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                                        AMERICAN PHYSICAL THERAPY ASSOCIATION
                                                     PTA CAUCUS

                           BIOGRAPHICAL INFORMATION AND CONSENT TO SERVE FORM

Please provide your preferred contact information:

 Name:                                                                    APTA Member #:

 Address:                                                                 E-mail:

                                                                          Contact Phone #:



Please check one box for each position indicating your willingness to serve in the following capacities:

                                                                                 I CONSENT                     I DO NOT CONSENT
                      CHIEF DELEGATE

                      DELEGATE

                      ALTERNATE DELEGATE

                      NOMINATING COMMITTEE


My indication of Consent to Serve may be published:                                        YES                    NO

As a nominee to elected office, my name may be published:                       YES              NO


Duties of the above positions are outlined in the PTA Caucus Procedure Manual. It is expected that the PTA Caucus Delegates will not be
restricted by their employment responsibilities from attending, and be willing to attend, in addition to the House of Delegates, CSM, and monthly
conference calls. Most Delegate expenses incurred during travel to the House of Delegates and CSM are reimbursed. The Alternate Delegate is
required to concurrently hold a State Representative position, and expected to be able to attend the PTA Caucus Meeting and monthly Delegate
conference calls. The Alternate Delegate is a non funded position. The PTA Caucus Nominating Committee will be willing and able to attend the
PTA Caucus Meeting and conference calls as needed. Most expenses incurred during travel to the House of Delegates are reimbursed. All are
expected to be responsive to electronic communications as part of conducting the business of the PTA Caucus.



Signature __________________________________________ Date _______________________________
(Electronic signatures will be accepted.)




PTA Caucus Biographical Information and Consent to Serve Form                                                                       1
Name:


Please complete the following membership information:


Chapter:


Section Memberships (List all)




Please complete the following information to assist the Nominating Committee in selecting a slate of candidates that
is diverse and thus representative of PTA membership:

Question:                                                    Response:
Have you been an APTA member throughout the past 2
years?

Please indicate your work setting. (eg, regional hospital,
outpatient practice, educational program)

Are you representative of a minority group?

Briefly describe your activity/contributions at district
and/or chapter level of APTA.




Briefly describe your activity/contributions at national
level of APTA.




Please briefly describe your experience, including venue,
with:
       Presiding over meetings




          Use of Roberts Rules




PTA Caucus Biographical Information and Consent to Serve Form                                            2
Name:
Question:                                                   Response:
Briefly describe your experience serving as a role model.




Briefly describe your experience serving as a mentor.




Are you a clinical instructor?
Are you a credentialed clinical instructor?

Briefly describe your efforts related to career
development (eg, continuing education, advanced
degree).




Are you a recipient of the Recognition of Advanced
Proficiency for the PTA?
Briefly describe your experiences communicating with
decision making bodies (eg, boards, trustees,
supervisors).




Briefly describe your experiences                           .
communicating/networking with other PTAs.




Briefly describe your experiences in team/group
participation.




PTA Caucus Biographical Information and Consent to Serve Form           3
Name:
Question:                                         Response:
Briefly describe your experiences in team/group
leadership.




PTA Caucus Biographical Information and Consent to Serve Form   4
Name:

Please briefly list/describe any other distinguishing characteristics, experiences, and/or contributions that you would like the
Nominating Committee to consider.




Thank you for your willingness to serve APTA!

If you have any questions, please do not hesitate to contact Janet Crosier. Please see below for contact information.

Please return your completed Biographical Information and Consent to Serve Form no later than
November 30 to:

                                                   Janet Crosier, PT, MS
                                                            APTA
                                                  1111 North Fairfax Street
                                                Alexandria, VA 22314-1488
                                                   janetcrosier@apta.org
                                              Phone: 800/999-2782, ext. 8514
                                                    Fax: 703/706-3387




PTA Caucus Biographical Information and Consent to Serve Form                                                             5

				
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