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1. ASHHRA 2016 for 2017 Regional Consultant Nomination Form

Thank you for your interest in serving as an ASHHRA Regional Consultant (RC). Please take a few minutes to review the RC Position Description and eligibility requirements on www.ashhra.org -- click on About ASHHRA, Governance and Regional Consultant Charges. To be considered as a candidate, this form must be completed by August 12, 2016 (Aug. 22 for Region 4). Candidates will be interviewed and notified within a reasonable amount of time, with a 30-day electronic voting period for Regions 2, 4, 6 and 8. Final results will be announced to all candidates in the fall. (If info below is on your resume, you may indicate "See resume."

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* 1. Personal Information

Name:

Title:

Organization:

Address:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

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* 2. How many years have you worked in health care HR and/or a related field?

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* 3. Position seeking

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* 4. I plan to attend the September 24-27, 2016, Annual Conference in Grapevine, Texas.

Yes

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* 5. I have read the job description for the Regional Consultant position for which I am applying and understand the time commitment required to serve.

Yes

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* 6. Work Experience
Please provide the positions/titles, dates of positions, organizations/agencies, and a brief summary of your duties starting with your present position.

Position/title:

Organization:

Dates Employed From/To:

Brief summary of your duties:

Position/title:

Organization:

Dates Employed From/To:

Brief summary of your duties:

Position/title:

Organization:

Dates Employed From/To:

Brief summary of your duties:

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* 7. List your special strengths, skills or talents related to being a Regional Consultant.

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* 8. Describe your professional experience, especially as it is related to being a Regional Consultant.

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* 9. Educational Preparation
Please provide the name of your School/College/University, location (city/state), and the degree granted and major.

Name of School/College/University:

Location (City/State):

Degree granted & Major:

Name of School/College/University:

Location (City/State):

Degree granted & Major:

Name of School/College/University:

Location (City/State):

Degree granted & Major:

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* 10. Briefly list by year your activities/accomplishments in ASHHRA at the local Chapter level.

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* 11. Briefly list by year your activities/accomplishments in ASHHRA at the National and/or Regional levels.

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* 12. Briefly list by year your activities/accomplishments of your membership in Local, State, and National Organizations -- OUTSIDE of ASHHRA (include offices held and dates).

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* 13. List all honors you have received (list the honors, dates and brief description of the reason for recognition).

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* 14. Time Management - Volunteers must meet deadlines, complete tasks and attend a variety of meetings/events as an ASHHRA representative. Please share how the responsibilities of your volunteer position will fit with the demands of your job.

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* 15. Why are you the best qualified candidate for this position? (Personal statement to appear on ballot.)

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* 16. What unique skills and experience do you bring to the specific position you are seeking?

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* 17. How do you think you reflect the HR Leader Model competencies in your professional life?

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* 18. How would you like to reflect those HR Leader competencies as a Regional Consultant?

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* 19. Why are you seeking this volunteer opportunity at this time?

Thank you for your interest and support of ASHHRA. Your submission is much appreciated. Now please email your resume and high resolution (300dpi) photo to ashhra@aha.org with Regional Consultant in the subject line. Your submission will be acknowledged via email.

If you should have questions in the meantime, please email ashhra@aha.org or call 312-422-3720.

Question Title

* 1. Personal Information

Question Title

* 2. How many years have you worked in health care HR and/or a related field?

Question Title

* 3. Position seeking

Question Title

* 4. I plan to attend the September 24-27, 2016, Annual Conference in Grapevine, Texas.

Question Title

* 5. I have read the job description for the Regional Consultant position for which I am applying and understand the time commitment required to serve.

Question Title

* 6. Work ExperiencePlease provide the positions/titles, dates of positions, organizations/agencies, and a brief summary of your duties starting with your present position.

Question Title

* 7. List your special strengths, skills or talents related to being a Regional Consultant.

Question Title

* 8. Describe your professional experience, especially as it is related to being a Regional Consultant.

Question Title

* 9. Educational PreparationPlease provide the name of your School/College/University, location (city/state), and the degree granted and major.

Question Title

* 10. Briefly list by year your activities/accomplishments in ASHHRA at the local Chapter level.

Question Title

* 11. Briefly list by year your activities/accomplishments in ASHHRA at the National and/or Regional levels.

Question Title

* 12. Briefly list by year your activities/accomplishments of your membership in Local, State, and National Organizations -- OUTSIDE of ASHHRA (include offices held and dates).

Question Title

* 13. List all honors you have received (list the honors, dates and brief description of the reason for recognition).

Question Title

* 14. Time Management - Volunteers must meet deadlines, complete tasks and attend a variety of meetings/events as an ASHHRA representative. Please share how the responsibilities of your volunteer position will fit with the demands of your job.

Question Title

* 15. Why are you the best qualified candidate for this position? (Personal statement to appear on ballot.)

Question Title

* 16. What unique skills and experience do you bring to the specific position you are seeking?

Question Title

* 17. How do you think you reflect the HR Leader Model competencies in your professional life?

Question Title

* 18. How would you like to reflect those HR Leader competencies as a Regional Consultant?

Question Title

* 19. Why are you seeking this volunteer opportunity at this time?

* 6. Work Experience
Please provide the positions/titles, dates of positions, organizations/agencies, and a brief summary of your duties starting with your present position.

* 9. Educational Preparation
Please provide the name of your School/College/University, location (city/state), and the degree granted and major.