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Board Nomination Form

Application Process and Criteria

Nominee Full Name(*)

Please let us know your name.

Nominee Email(*)

Please let us know your email address.

PTSBC Membership Number of Nominee(*)

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Primary practice setting of the Nominee(*)

Select a practice settingCommunityHospitalOther

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Reason for Nominee to be selected. (*)

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Nominee Biography(*)

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Upload a photo of the Nominee (*)

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Nominator Full Name (if any)

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Nominator Email (if any)

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Nominee accepts that if elected he/she is prepared to serve a term of:(*)

Nominee accepts that if elected he/she is prepared to serve a term of:

minimum (1) year

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By submitting this application form electronically, the Nominee and Nominator is deemed to have signed the application form.

Captcha(*)

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SUBMIT NOMINATION FORM

Monday, August 25, 2025

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