First Name
Last Name
School/Organization
Address Line 1
Address Line 2
City
Province/Territory	- Select a Province - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Postal Code
Telephone Number
E-mail Address

Nominator 1 Name
Nominator 1 Telephone
Nominator 2 Name
Nominator 2 Telephone

Position applied for
- Select a Position - Alberta Director British Columbia Director Manitoba Director New Brunswick Director Newfoundland and Labrador Director Nova Scotia Director Ontario Director Director at Large Prince Edward Island Director Quebec Director Saskatchewan Director Territories Director

Please explain why you have decided to apply for this position. What do you feel you can contribute to the Association as a member of the Board of Directors? (250 words or less)

Please include a photo of yourself. You may upload a photo in either JPEG or GIF. (optional)
Photograph