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*Region I (CT, MA, ME, NH, NJ, NY, RI & VT)Region II (AL, DE, DC, FL, GA, MD, MS, NC, PA, SC, VA, WV)Region III (IL, IN, KY, MI, OH, TN WI)Region IV (AR, IA, KS, LA, MN, MO, OK, ND, NE, SD, TX)Region V (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY)Nominee HOME Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Candidate Statement (No more than 250 words):*Areas of responsibility within your organization (administrative, operational, billing, etc.):*About Your Ambulance ServiceNumber 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.CommentsThis field is for validation purposes and should be left unchanged.