AVMA DIRECTOR OF INTERNATIONAL AFFAIRS
	APPLICATION & NOMINATION FORM
PLEASE PRINT OR TYPE

AVMA Director of International Affairs	
Position Name	

APPLICANT INFORMATION:

     	

     	
Name of Individual	AVMA ID#	

                                                                                             	
Address, City, State, Zip	

     	
     	
     	
Office Phone	Cell/Home Phone	Email Address	

     	
Present Professional Activity or Employment (Type of Work or Position Designation) 
Eligibility for committee appointments is based on professional classifications in AVMA member records.  Please ensure your professional activity information is current at the AVMA website: www.avma.org. 	

Why are you interested in serving on this committee? (150 word limit, continue on separate page if needed)
	
     	

     	

What attributes would you bring to this committee? (150 word limit, continue on separate page if needed)
	
     	

     	

AGREEMENT TO SERVE - I agree to serve on the Committee if elected, and I am professionally active in the area specified, if any, for the position to which I am applying.  I certify that the information provided above is true and accurate to the best of my knowledge. 

     	
*Signature of Applicant

INDIVIDUAL OR ORGANIZATION SUBMITTING NOMINATION:	

     	
     	 
                         	
Name	Title                             	Email Address	

     	
Nominating Organization

     	
Address	

     	
     	
     	
*Signature of Nominator	Title	Date	

Nominations must be received by the Office of the Executive Vice President.
Please include a resume (2 page maximum, single-sided) of the applicant’s qualifications.

Email application to OfficeEVP@avma.org, fax to 847-925-0944, or mail to 
AVMA Office of the Executive Vice President, 1931 N. Meacham Road, Suite 100, Schaumburg, Illinois 60173.

*By typing your name you agree that this is valid as your signature.