AMA Nomination Form: American Board of Emergency Medicine (July 2012) Survey

On behalf of the American Medical Association (AMA), thank you for your nomination. Please complete the following 22 questions on this application form to initiate the nomination process. Once you have completed this form, send a current summary of your CV (maximum 3 pages) to evelyn.sherrill@ama-assn.org. If you have any questions, please contact Evelyn Sherrill at (312) 464-4515.

1. Nominee information

Nominee information First Name
Middle Initial
Last Name
Credentials (e.g., MD, PhD)
Address1
Address2
City
State
Zip Code
Phone Number
Fax Number
Email Address
Alternate Email Address

2. Date of birth

	MM		DD		YYYY		HH		MM	AM/PM
Date	Date of birth Date Month	/	Day	/	Year		Hour	:	Minute	AM or PM

3. Place of birth

Place of birth

4. Medical school

Medical school

5. Year graduated from medical school

Year graduated from medical school

6. Medical specialty

Medical specialty

7. Board certification(s)

Board certification(s)

*

8. Nominee is an AMA member

Nominee is an AMA member Yes

No

AMA member since:

9. Nominee is an AMA delegate

Nominee is an AMA delegate Yes

No

10. Nominee has agreed to serve

Nominee has agreed to serve Yes

No

11. This nomination is submitted by the following (insert email address)

This nomination is submitted by the following (insert email address)

12. I nominate the above individual for the following American Board of Medical Specialties (ABMS) specialty board position(s) (check all that apply):

I nominate the above individual for the following American Board of Medical Specialties (ABMS) specialty board position(s) (check all that apply): Emergency Medicine