WSCA Board Appointee Application

Please complete and submit this form to be considered for appointment to the vacant position on the WSCA Board of Directors.

Name *

First

Last

Email *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home or Cell Phone *

Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

If you are currently in practice, you must indicate your clinic address.

Clinic Phone

If you are currently in practice, you must indicate your office phone.

Chiropractic College *

Graduation Year *

Years Licensed in Washington *

Other Jurisdictions Where You Are Licensed

Years of Membership in the WSCA *

Are you available for 2-4 hours in the morning of the first Thursday of each month for in-person or online meetings? *

Are you currently employed by, or related by blood or marriage to, a current member of the WSCA Board of Directors? *

To the best of your knowledge, do you have any conflicts of interest that may affect your ability to impartially represent your district? *

If so, please explain:

Are you now, or have you ever been, subject to disciplinary action from the CQAC or another state's regulatory commission? *

If so, please explain:

What role do you view the WSCA Board of Directors as having? *

Please describe your practice: *

Please tell us why you want to serve on the WSCA Board of Directors: *

Please list the names, addresses, phone numbers, and emails of two (2) current WSCA members who either reside or work within the district you are seeking to represent who would endorse you serving in this role: *

You do not need to secure their endorsements--just provide the names and contact info of two members who would endorse you, if asked.

Please confirm that the foregoing answers are true and accurate, to the best of your knowledge. *

I so confirm

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