I am an AGS Member? (Please Note: You must be an AGS Member to sit on an AGS Committee)
 Yes
 No

When did you become an AGS member?
YEAR 

Have you served/or are you currently serving on an AGS Committee?
 Yes
 No

If Yes which one, and when did you serve?



If No, have you applied for Committee Service in the past?
 Yes
 No

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 rank the committees you are interested in serving on in order of preference
(Rank only those you are interested in serving on, using 1 to indicate first preference)

1 2 3 4 5 6 7 8 9	Clinical Practice & Models of Care
1 2 3 4 5 6 7 8 9	Education
1 2 3 4 5 6 7 8 9	Ethics
1 2 3 4 5 6 7 8 9	Ethnogeriatrics
1 2 3 4 5 6 7 8 9	Health Economics & Technology
1 2 3 4 5 6 7 8 9	Nominating
1 2 3 4 5 6 7 8 9	Public Education
1 2 3 4 5 6 7 8 9	Public Policy
1 2 3 4 5 6 7 8 9	Quality & Performance Measurement Committee
1 2 3 4 5 6 7 8 9	Research

Please describe why you have selected this committee and what you could contribute as a committee 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 Thursday, December 20, 2007:

• Two letters of support from current AGS Board and/or Committee members.
• A 2-page biographical sketch or short curriculum vitae