Committee Interest

Committee Interest is not available at this time.

2010-11 Online Committee Interest Form PLEASE NOTE: Current committee members DO NOT need to complete a committee interest form. They will be asked to fill out the committee evaluation form soon to indicate their preferences for next year. This is for any member not currently on any committee.

Name:
Member Number:
Year Joined ACEP:
Chapter Affiliation:
E-mail Address:
ACEP Member:	YesNo
EMRA Member:	YesNo
Current Member of the following sections: (List All) (a) (b) (c)

Business Address
Business Name:
Address:
City:
State:
Country:
Zip:

Home Address
Address:
City:
State:
Country:
Zip:
Please check preferred address	BusinessHome
Business Telephone:
Home Telephone:
Please check preferred telephone number	BusinessHome
I would like to serve on the following committee(s) or task force(s): (Please list in order of preference) (a) (b) (c)
For each committee or topic listed above, indicate qualities or experience that you would bring to this committee that would cause you to be selected:
(a)
(b)
(c)
I am currently serving on the following committee(s) at the chapter level:
(a)
(b)
(c)
I have previously served on the following committee(s) at the chapter level:
(a) Year
(b) Year
(c) Year
I am currently serving on the following committee(s) at the national level:
(a) (b) (c)
I have previously served on a committee(s) at the national level:
(a) Year
(b) Year
(c) Year
Last year I submitted a committee interest form and was not selected for any committee: YesNo

Curriculum Vitae
Please attach your current CV if you are not currently serving on a National ACEP committee. If you cannot attach your CV to this form electronically, please mail it to Rochelle Ross at the address listed below. You must submit a CV to be considered.


Chapter Letter of Support (optional)
All members volunteering for an ACEP committee are encouraged to ask their chapter for a letter of support. It is not mandatory that you attach or send a letter of support to be selected to serve on an ACEP committee. If you cannot attach your letter of support to this form electronically, please mail it to Rochelle Ross at the address listed below.

All materials must be received by May 17, 2010.


Rochelle Ross ACEP P.O. Box 619911 Dallas, TX 75261 800-798-1822 ext 3145 972-580-2816 fax rross@acep.org