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Board Candidate Form

Your nomination form is due Friday, June 17th.

Election Nomination Form - 2022

Nominee Name:*
First Last
Email*
Phone*
Job Title*
Company*
Candidates must be employed by an AAA active member organization.
Position(s) You Are Interested in Running For?*
- President-Elect
- Treasurer
- Secretary
- Region 1 Director
- Region 2 Director
- Region 3 Director
- Region 4 Director
- Region 5 Director
- Ethics Committee
Nominee Region*
Nominee HOME Address:*
Street Address Address Line 2 City State ZIP Code
Candidate Statement (No more than 250 words):*
Areas of responsibility within your organization (administrative, operational, billing, etc.):*
About Your Ambulance Service
Number of Ground Ambulances*
Number of Employees*
Does the ownership or Board of your organization commit to your travel and full participation for your term?*
- Yes
- No
Past involvement with AAA (Committees, etc.):*
Current or past EMS certifications (EMT, Paramedic, etc.) and year certified:*
Years in the ambulance industry:*
Brief history of career in EMS:*
What would you identify as the top three issues in emergency healthcare?*
What do you believe are the three priorities for the AAA?*
Headshot Photo*
Please upload a recent headshot photo for inclusion on the candidate page.
Accepted file types: jpg, gif, png, eps, Max. file size: 1 MB.
Comments
This field is for validation purposes and should be left unchanged.

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