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CCPAC Board of Trustees Nomination Form - Districts 1 & 2
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Name:
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Your answer
E-mail:
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Your answer
Cell Phone Number:
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Your answer
Physical Address:
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Your answer
Mailing Address (if different from physical address):
Your answer
CalChiro Member Since:
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Your answer
CalChiro District:
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Your answer
Please mark the PAC District for which you are applying:
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District 1: Contra Costa, North Bay, North District and Sacramento Valley
District 2: Alameda County, Central Valley, Monterey Bay, San Francisco, San Mateo County, Santa Clara County, and San Joaquin/Stanislaus
Membership must be in good standing at the time of application and nomination. Is your CalChiro membership in good standing?
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Yes
No
Are you a regular CCPAC contributor?
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Yes
No
Required
Check all the CalChiro Legislative activities below you have supported over the past three years:
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Written Letters to Legislators
Attended CalChiro Legislative Conferences
Made Phone Calls to Legislators
Served as a CalChiro Key Doctor
Met with my State Legislators
Other:
Required
Why do you want to serve on the CalChiro PAC Board of Trustees?
Your answer
Have you ever been cited by the CA Board of Chiropractic Examiners for a violation of the Chiropractic Initiative Act or related rules governing professional conduct or been convicted of any felony or misdemeanor involving moral turpitude, dishonesty or corruption?
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Yes
No
By entering your name below you are acknowledging and verifying all information provided is accurate and true:
Your answer
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