The American Geriatrics Society - About - 2008 AGS BOARD Nominee Information Form

2008 AGS BOARD Nominee Information Form
Nominations for committee service commencing in May of 2008
open on June 1, 2007 and run through October 1, 2007

Nominations for committee service commencing in May of 2008 open on
June 1, 2007 and run through October 1, 2007

First Name
Last Name
Degrees
Primary Email Address
Primary Phone Number

Are you a current AGS Member?
(Please Note: You must be an AGS Member to sit on an AGS Committee or Board)
Yes

When did you become an AGS member?
YEAR

Have you served/or are you currently serving on any AGS Committees?
Yes
No

If Yes which one, and when did you serve?

Which other AGS activities are you currently active in?
Please check all that apply.
Serve on a Subcommittee, specify
SWAT team member, specify
AGS spokesperson
Contribute to FHA Stories website
Participate in the FHA Referral Service
Volunteer Mentor
Work on a special project, specify
Other, please specify,

Please describe why you would like to sit on
the AGS Board what you could contribute as a Board member:
Please limit to 200 words or less

Please provide a brief summary of your professional background:
Please limit to 200 words or less

What organizations are you currently a member of?
Please limit to 200 words or less

I am aware that in order for my application to be complete I need to also
submit the following documents to ccampanelli@americangeriatrics.org by
Monday, October 1, 2007:

A 2-page biographical sketch or short curriculum vitae

Letter of Support from a current or past AGS Board member**

** Please Note: If you have been nominated by a current or past Board Member,
the completed 'Board Nomination Form' can serve as your letter of support.
If not, AGS staff will follow-up with you, and ask you to obtain a letter of
support in order to complete your application