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FAX RESPONSE FORM
Please return by fax or mail to Amy Tam-Liao
Due December 31, 2003
Amy Tam-Liao
Professional Education and Publication
American Geriatrics Society
350 Fifth Avenue, Suite 801, New York, NY 10118
Tel: 212-308-1414 Fax: 212-832-8646
If you would like to nominate either a colleague or yourself to run for the AGS Fellows-In-Training Chair-Elect position, please submit a statement, of 150 words or less, in support of your nominee. You may type or print this statement in the space below or on a separate sheet of paper.
Name:______________________________________________________________________
Address:____________________________________________________________________
City:____________________________________________State:___________Zip:_________
Phone:______________________________________________________________________
Fax:____________________________________Email:_______________________________
Statement:
___________________________________________________________________________
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___________________________________________________________________________
___________________________________________________________________________
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