International Organisation of Societies for Electrophysiological Technology

Fiscal Period 2011-2015 Officer Candidate Profile Form

Return by January 4, 2010

The form and responses can be duplicated and e-mailed as long as the information contains the required material and follows this format. Send completed form via e-mail to Arlen Reimnitz, ASET Executive Director, at . Follow by mailing hard copy of materials to Arlen Reimnitz, ASET Executive Office, 6501 East Commerce Avenue, Suite 120, Kansas City, MO 64120 for receipt by January 8, 2010.

______

NameTitle/Position

Candidate for  President  Secretary Treasurer  Member at Large

Preferred Mailing Address  Home  Work E-mail

Company/Organization: ______

Street Address: ______

City/State/Postal Code: ______

Daytime Telephone #: ______E-mail Address: ______

_American Society of Electroneurodiagnostic Technologists, Inc.______

Name of your national society

__6501 East Commerce Avenue, Suite 120______

Contact Information for your national society: Street/Mailing Address Dept./Bldg.

__KansasCity, Missouri______USA______64120______

CityCountryZip Code (if applicable)

__317.962.8563______317.962.7954______

Society President PhonenumberSociety President Work Fax

______

Society President E-mail Address

Below is a list of requirements necessary to complete this nomination form. Please use the check off boxes as a tool for your self to make sure all requested information is sent to the nominations chair. This information is requested on separate sheets of paper.

 Education & Training of Candidate:

Please list education and training:

  Employment History

[Please list position/title, employer, length of employment with the most recent experience first. Please follow the format and example: Supervisor of EEG Lab, Memorial Hospital, Denver, CO, 1986-1990]

 Professional Contributionswithin your country or internationally

[Due to space limitations, please limit your contributions to 10 entries which can include published articles, officer positions or volunteer activities held with professional organizations, etc. Examples: EPTA NCS Course Speaker, 2001; AITN President, 2001-02]

 Professional Awardswithin your country or internationally

  OSET Candidate Questions

[Please answer the following questions. OSET reserves the right to edit your response accordingly, but you will have an opportunity to approve your listing prior to printing and distribution.] This should be submitted on a separate sheet.

  1. Describe any experience or skills you have gained in a leadership role with other organizations that will assist you as an OSET officer.
  1. What qualities do you have that would make you a good officer?

References

Provide two professional references, including their position/title, place of employment, address, direct phone, fax and e-mail address. State your professional relationship with each reference [i.e. professor, co-worker, supervisor, etc.].

Society Letter of Support

Include letter of support from your current society President that includes their position/title, place of employment, and e-mail address. The letter should serve as a reference and verification of nomination from your society. This letter should be signed and dated.

Candidate Letter of Support

Include letter of acceptance for the position being nominated. This letter supports the society President’s letter of agreement to run for the office specified. This letter should be signed and dated.

OSET Bye-Laws and Constitution



 I have read the entire current Bye-Laws and Constitution and agree to abide by those rules as the true and only rules of the OSET society.

I have read the responsibilities outlined and am willing to commit the time, energy and support resources necessary to fulfill my duties and obligations as an OSET officer, if nominated and elected.

Signature______Date______

For more information, contact Margaret Walcoff, Nominating Committee Chair. E-mail:

1