Election Nomination Form

Nominee Name:*

First Last

Email*

Cell Phone*

Job Title*

Company*

Candidates must be employed by an AAA active member organization.

Nominee Region*

Position(s) You Are Interested in Running For?*

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?*

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 medical services?*

What do you believe are the three priorities for the AAA?*

*High Resolution* 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.

Phone

This field is for validation purposes and should be left unchanged.