First Name:  Last Name:

Phone:     Email Address:

College: AHS Dentistry GHS Medicine Nursing Pharmacy

Anticipated Graduation Date: 2013 2014 2015 2016

Desired Position:
President Vice President Treasurer Secretary Logistics Coordinator Funding Director

What skills do you have that are directly applicable to the indicated position?

What other skills do you have that you feel will be beneficial to the WIMS Executive Team?

List 1-3 ideas that you have for the following WIMS focus areas: (1) Professional development, (2) mentorship, and (3) outreach.

How many hours per week are you willing and able to dedicate to WIMS-related responsibilities?

Why are you applying for this position?

Identify any specific strength(s) would you bring to this organization:

Increasing support/participation for WIMS Event organization/execution Web design
Grant writing Recruiting mentors Fundraising

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