Elections

OMA Ethics Committee Application

First Name: __________________________ Middle Name/Initial: ______ Last Name: __________________________ Academic Designation & Professional Credentials (e.g., MD, DO, FAAFP, PA, NP, etc.): _______________________ For which position are you interested in applying? □ Ethics Committee

List your involvement with OMA committees: Committee name

Position Year(s) served on committee _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ List any other professional societies or associations in which you are or have been: a member or a board or committee member, and describe your level and length of involvement (e.g., committee chair, board member, general member, etc.). Note: active board or committee activities in acknowledged competitive professional societies or associations may be a disqualifying factor, if so determined by the Nominating Committee. Association name Level of involvement _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ List any other professional activities (e.g., publishing, non-OMA speaking engagements, faculty positions, etc.) Activity Dates of activity _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Can you commit to serve a minimum of two years on the Ethics Committee? _________________________________________________________________________________________________ Application continues on next page.