NSSLHA Executive Council Consultant Application

Applicant Information

Applicant First Name:*

Applicant Last Name:*

ASHA Account Number:

Region (locate your region):*

Are you currently a local NSSLHA chapter advisor?

Chapter Name:

Area of Professional Interest (e.g., pediatrics, swallowing, audiology):

Contact Information

Mailing Address (all correspondence will be sent to this address):

City:

State:

(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone Number:*

Fax:

E-mail:*

Assurances

I understand that the consultant position on the NSSLHA Council is a voluntary position with a three-year term.*

I understand that it is essential that the consultant attend three NSSLHA Executive Council meetings (one meeting occurs during the ASHA Convention in November; the other meeting is held in the spring at the national office in Rockville, Maryland and there is an orientation in the summer).*

I understand that if selected this position may require 5 - 8 hours per month of my time engaged in conference calls or work assignments on behalf of the Executive Council and/or the association.*

Race/Ethnicity

One of NSSLHA's goals is to have its membership represent the multicultural diversity of American society.

Tribal Affiliation (for American Indians - including Alaskan Natives):

Resume

You may cut and paste your resume or curriculum vitae from a Word document into this area or send your resume or CV to nsslhaprograms@asha.org as a separate attachment. If you choose to send your resume or CV via e-mail, please type "sending via e-mail" in the space provided. If you are copying and pasting your resume below, please note that any formatting in Word will not transfer into the following box.*

Statement of Interest

Please provide the NSSLHA Executive Council with a statement that explains your interest in the position. Please answer all questions and limit your responses to 500 words or less.

I am interested in this position because…*

In my professional career, I am most proud of…*

During my three-year term on the council, I will be successful if …*

I will manage the responsibilities of the position and my paid work assignments in the following way…*

References

Please have one professional and one student provide a letter of support on your qualifications for this position. Letters of support must be received electronically to nsslhaprograms@asha.org.