Exit this survey >> 2012 Practice Division Director Application Thank you for your interest in applying for the ASSH Council's Practice Division Director position. Please complete the following online application and email your electronic CV (your CV may not exceed four (4) pages in length) to Alexzandra Wallace at awallace@assh.org. Send your letters of support via email only to: Alexzandra Wallace awallace@assh.org You are also required to complete the ASSH Conflict to 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. ou will be asked to login to the ASSH website. Select the "Edit" button in the lower right corner, and then click on “update your disclosures.” The deadline to apply is March 30, 2012. Qualifications and Commitments Please read through the qualifications and commitments expected of all Council members, Council Conflict of Interest Policy, and the specific duties of this position before proceeding. You are required to complete the ASSH Conflict to Interest Disclosure. To complete your disclosure, please visit the ASSH website in the My Profile section. Click on "Edit" in the lower right corner, and then click on the "Conflict of Interest" tab. Question Title * 1. Please enter your name and email address. Last Name First Name Email Question Title * 2. I have read the description for 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. If elected to the Practice Division Director position, I will serve the complete three year term. Agree Disagree Question Title * 4. Year you joined 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 In the questions below, please indicate what past volunteer contributions you have made to the ASSH and when they took place in the following categories: Committees, Course chair, and Instructor. Question Title * 7. Committees Question Title * 8. Course Chair Question Title * 9. Instructor Question Title * 10. Areas of interest/expertise within medicine that would enhance your Council board participation: Question Title * 11. Interests outside of medicine that could enhance your contributions to the Hand Society in general: Please use the space provided to note your experiences that are specific to Practice Management Question Title * 12. Please list any Leadership Positions you have held in the following areas: Medical Organizations/Societies Practice Groups: Hospital: Volunteer Organizations Question Title * 13. Experience with Advocacy and/or Government affairs: Question Title * 14. Any skills that are specific and applicable to the Practice Director position: Question Title * 15. What experience do you have within this division that is relevant to your application for this director position? Question Title * 16. What is your vision for the evolution of the Practice Division in the next three years? Question Title * 17. Names of 2 ASSH members who will be writing letters of support. Note: It is your responsibility to have these two members email their letters of support to Alexzandra Wallace awallace@assh.org at the ASSH Central Office by March 30, 2012. 1st member 2nd member Done >>