Oregon Physical Therapy Association

OPTA Candidate Nomination
& Biographical Form

Please complete this nomination form in its entirety. Comments you provide below may be summarized for publication in the candidate information literature we send to members prior to the business meeting.

Required information is marked by an asterisk (*)

This nomination form is being filled out by:
	The candidate
	An OPTA member nominating a candidate
	Please list name:

Position for which this nominee is a candidate:

Name*:
APTA Membership Number:
Home Address
City, State, Zip:
Home Phone:
Company Name:
Work Address:
City, State, Zip:
Work Phone:
Work Fax:
E-mail*:

To the best of my knowledge my place of employment:

	is a "referral for profit" employment setting.
	is not a "referral for profit" employment setting.

Employment history & practice interests
(summarize briefly):

OPTA Activities:

APTA Activities:

Publications, Research, Professional Awards:

Comments:

Copyright © 1999 Oregon Physical Therapy Association
147 SE 102nd Avenue, Portland, Oregon 97206
Phone: 503.262.9247 * Toll-free: 877.452.4919
Fax: 503.253.9172
Email: info@opta.org

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