Elections

What do you envision as the top 3 goals or objectives that are most important for the Ethics Committee and why? 1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ How do you think your talents, core competencies, personal attitudes, and skills make you a good candidate for this position? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ List three reasons why you wish to serve on the Ethics Committee and explain why they will be an asset to the OMA. This information will be included on the ballot. 1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ In what ways do you think OMA could improve and why? This information will be included on the ballot. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Are you now, or have you ever been, under any investigation by any state regulatory agency concerning your license to practice medicine? If yes, please state the disposition of the proceedings. _________________________________________________________________________________________________ Are you now, or have you ever been, under any investigation by any federal regulatory agency (e.g., DEA, FDA, or FTC)? If yes, please state the deposition of the proceedings. Indicate if you do not wish to answer this question on the grounds of confidentiality. _________________________________________________________________________________________________ Please list (if any) products, films, publications, or promotional advertising wherein you allow your name to be associated or otherwise give your endorsement. _________________________________________________________________________________________________

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