2024 District Consent to Serve Form
If you wish to run for office, please fill out this form and return it to the District Committee on Nominations Chair. Please print or type the information requested below:
Name _________________________________________
Current Professional Credentials: __________________
MNA Membership No. _______________ Member of District #: ___
Date MNA Membership Started: ________
Address ____________________________________________________________________________________________
City ________________________________________ State _______ Zip _______________________________
PHONE: Home ________________________Work _________________________ Cell:____________________
EMAIL:Work:_________________________________________Personal:______________________________
Circle Preferred Email: Work or Personal
I want my name placed on the ballot for(position):
_______________________________________________
I consent to serve for the following term (dates): ______________________________
EDUCATION: List formal education degrees awarded, year awarded & institution from which awarded degree:
_____________________________________________________________________________________________
Current Certifications & Date of Expiration:
________________________________________________________
Current Employer & Job Title:
___________________________________________________________________
Current offices you hold in nursing organizations (specify local, state, national)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
If elected to the above office, I promise to serve the District Nurses Association (DNA) to the best of my ability in the promotion of the platform adopted by the DNA membership in the best interest of nurses and nursing in Maryland.
Candidate Signature & Date__________________________________________________________________
District President Signature & Date: ________________________________________________________
Please submit this form plus 1) A description (200 words or less) about why you are interested in serving and what qualifies you for the office/position. Please send the essay in a separate Word document. 2) OPTIONAL: email a head & shoulder photo (JPEG format) Return to District CON chair who in turn will forward to MNA CON & MNA ED