Nominees who seek a statewide leadership position must complete a Consent to Serve and Resume Form, which will include demographic information, NPO membership history information and a signed affirmation form.

Nominees must complete a separate form for each position they are seeking.

Failure of a nominee to provide a completed and correct Consent to Serve by the deadline will result in the appropriate nominating committee excluding a nominee from the ballot. The Nominating Committee will provide the nominee written notice of its reasons for excluding the nominee from the ballot.

Offices/Appointments with the Nurse Practitioners of Oregon

Office or position *

Name: *

Former name(s) if applicable:

Pronouns:

Personal email address: *

Confirm email address *

Current employer: *

Credentials

Street address: *

City *

State *

Zip code *

Cell phone number *

Work number