PTAG Board of Directors & Leadership Election | Candidate Submission 2018

  1. Thank you for your interest in serving your association! Should you have any questions while completing this form, please contact the PTAG Executive Office: info@ptagonline.org OR 770-433-2418.

    Information provided will be used verbatim in Nominating Brochure. Please check spelling, grammar and accuracy before submitting.
  2. First Name & Last Name(*)
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  3. Credentials(*)
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  4. Email(*)
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  5. Phone (000-000-0000)(*)
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  6. In which PTAG LAN do you reside?(*)
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  7. For what PTAG position are you running?(*)
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  8. Education
    Please provide your educational history in consecutive order (undergraduate, graduate, post-graduate, etc.).
  9. School(*)
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  10. Degree(*)
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  11. School
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  12. Degree
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  13. School
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  14. Degree
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  15. School
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  16. Degree
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  17. Employment
    Please list your current place of employment.
  18. Employer (Primary)(*)
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  19. Position(*)
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  20. Employer (Secondary)
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  21. Position
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  22. Years of Membership
  23. APTA ID #(*)
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  24. APTA Membership Expiration Date(*)
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  25. # of Years as an APTA Member(*)
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  26. # of Years as a PTAG Member(*)
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  27. Georgia PT/PTA License #(*)
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  28. Volunteer
    Please list PTAG and other involvement.
  29. PTAG Involvement(*)
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  30. Other Chapter, Region, Section or National Involvement(*)
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  31. Statement
    Please answer briefly and in complete sentences.
  32. What do you believe are the major responsibilities for the office that you are running for in the coming term?(*)
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  33. If elected, what will be your contribution to the position?(*)
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  34. Headshot
    Please attach your current headshot here in .jpg, .png, or .gif format. This will be used in the Nominating Brochure and online election materials.
  35. Upload your current photo(*)
    You must attach a photo of yourself to be used in nominating/election materials.
    please use a high-res image.

  36. By submitting this application, I swear that to the best of my knowledge:
    I am eligible to hold an elected position in the Physical Therapy Association of Georgia by virtue of my compliance with ethical, legal and moral standards of the profession of physical therapy.

    I have read and agree to the Policy & Procedures of the elected position for which I am submitting. I also attest I have read & meet the required qualifications of this position.

    I have not been reprimanded nor has my license been sanctioned within the last 3 years. I furthermore attest that I am licensed as a Physical Therapist/Physical Therapist Assistant in the state of Georgia and a member of the Physical Therapy Association of Georgia. I am in good standing with the Georgia State Board of Physical Therapy.

    Therefore, I do hereby agree to abide by the standards of practice and the code of ethics of the American Physical Therapy Association and the Physical Therapy Association of Georgia.(*)
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