Elections

Since becoming a member of OMA, have you engaged in any activity that may have been a misrepresentation of your official position, title, or professional qualifications? If yes, state the particulars.

If elected and seated as a member of the OMA Board of Trustees, how would you react to a board decision with which you personally strongly disagreed?

Do you think you may have a potential conflict of interest or commercial involvement as outlined in the OMA Conflict of Interest Policy and Disclosure Statement that may prevent you or may be perceived by others as not allowing you to act solely in the best interest of the OMA while serving on the OMA Board of Trustees? If so, please provide a detailed overview on your disclosure form.

All OMA Board of Trustee candidates are asked to provide OMA with the proper authorization for a standard criminal, professional and education background check. Will you consent to a standard background check?

Signature:

Date:

How and What to Submit: Return this fully completed application and the signed OMA Conflict of Interest Policy and Disclosure Statement (COI), along with any supplemental attachments, to OMA by June 21,2021, at 5:00 PM EDT. Email: election@obesitymedicine.org Mail: 7173 S. Havana St, Suite 600 - 130 Centennial, CO 80112 Only fully completed applications and COIs will be considered for review.