2012 ASSH Council Application 100% of survey complete. Thank you for your interest in applying for the Vice President, or Council Member-at-Large, over eight year or under eight years, positions. Volunteer leadership is crucial to the success of our organization. All applicants are encouraged to attend the Members' Business Meeting at which the nominees will be presented for vote by the membership. The Members' Business Meeting will be held on Thursday, September 6th. Please complete the following online application and email your electronic CV (Please limit to four (4) pages in length) AND two letters of recommendation to Alexzandra Wallace at awallace@assh.org at the ASSH Central Office by July 16, 2012. You are also required to complete the ASSH Conflict of Interest Disclosure. Click here to view the ASSH Conflict of Interest Policy. To complete your disclosure, please visit the ASSH website in the My Profile section. Select "Disclosures" from the top, right corner, and then update. Question Title * 1. Please enter your name, email address and cell phone number. Name Email Cell number Qualifications and Commitments Please read through the qualifications and commitments expected of all Council members and the specific duties of each position. Vice President: To apply for the office of the Vice President an individual who shall have been an Active member for 5 years prior to the time of election shall be eligible for nomination as an officer. Prior service on Council is required. Member-at-large (Over and Under 8 years): To apply to be Member-at-large you must be an ASSH Active Member. Question Title * 2. I have read the description of the position for which I am applying, and I appreciate the responsibilities associated with such position. I hereby represent that, if appointed to such position, I will commit myself to the position and will fulfill such responsibilities to the best of my ability. Agree Disagree Question Title * 3. Please select the position for which you are applying. Vice President Council Member-at-Large - Membership OVER eight years Council Member-at-Large - Membership UNDER eight years Question Title * 4. What year did you join ASSH? Question Title * 5. Primary employer: Self-employed private practice Group private practice University Institution (Shriners, VA, Kaiser, etc.) Other (please specify) Question Title * 6. Board certification: Orthopedic surgery Plastic surgery General surgery Question Title * 7. Please describe past volunteer contributions you have made to ASSH COMMITTEES. Question Title * 8. Please indicate any ASSH COURSE CHAIR positions you have held in the past. Question Title * 9. Please indicate any ASSH INSTRUCTOR positions you have held in the past. Question Title * 10. Please indicate whether you have served on the AFSH BOARD in the past, and if so, indicate the position you held. Question Title * 11. Additional memberships (Please indicate any Board positions currently held that may present conflict in the "Other" box): None AAOS ASPS ACS AMA State Medical Society Other (please specify) Question Title * 12. Please indicate your areas of medical interest/expertise that would enhance your Council board participation: Question Title * 13. Please describe any interests you have outside of medicine that could enhance your contributions to the Hand Society in general: Question Title * 14. Please give names of two ASSH members who will be writing your letters of support. Note: It is your responsibility to have these two members email or mail their letters of support so they arrive c/o Alexzandra Wallace at the ASSH Central Office by July 16, 2012. Please note our new address! 822 W. Washington Blvd. Chicago, IL 60607 1st member 2nd member Question Title * 15. Additional comments (optional): Thank you for your online application. Please be sure that all of your completed application materials arrive at the Central Office by July 16, 2012: 1) Electronic CV (Please limit to four (4) pages in length.) 2) Two member letters of support 3) Completed conflict of interest disclosure Alexzandra Wallace ASSH 822 W. Washington Chicago, IL 60607 awallace@assh.org Fax: 847-384-1435 Select "done" below to submit your online Council Position Application. Done >>