2011 - 2012 Council Application

100% of survey complete.

Thank you for your interest in applying for the Vice President, Treasurer 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 8th.

Please complete the following online application and email your electronic CV AND two letters of recommendation to Alexzandra Wallace at awallace@assh.org at the ASSH Central Office by July 1, 2011.

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 "Edit" in the lower right corner, and then click on the "Conflict of Interest" tab.

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* 1. Please enter your name, email address and cell phone number.

Name

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.

Treasurer:
To apply for the office of the Treasurer 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.

Member-at-large:
To apply to be Member-at-large you must be an ASSH Active Member.

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* 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

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* 3. Please select the position for which you are applying.

Vice President

Treasurer

Council Member-at-Large - Membership OVER eight years

Council Member-at-Large - Membership UNDER eight years

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* 4. What year did you join ASSH?

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* 5. Primary employer:

Self-employed private practice

Group private practice

University

Institution (Shriners, VA, Kaiser, etc.)

Other (please specify)

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* 6. Board certification:

Orthopedic surgery

Plastic surgery

General surgery

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* 7. Please describe past volunteer contributions you have made to ASSH COMMITTEES.

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* 8. Please indicate any ASSH COURSE CHAIR positions you have held in the past.

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* 9. Please indicate any ASSH INSTRUCTOR positions you have held in the past.

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* 10. Please indicate whether you have served on the AFSH BOARD in the past, and if so, indicate the position you held.

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* 11. Additional memberships:

None

AAOS

ASPS

ACS

AMA

State Medical Society

Other (please specify)

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* 12. Please indicate your areas of medical interest/expertise that would enhance your Council board participation:

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* 13. Please describe any interests you have outside of medicine that could enhance your contributions to the Hand Society in general:

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* 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 1, 2011.

1st member

2nd member

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* 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 1, 2011:
1) Electronic CV
2) Two member letters of support
3) Completed conflict of interest disclosure
Alexzandra Wallace
ASSH
6300 North River Road, Suite 600
Rosemont, IL 60018
awallace@assh.org
Fax: 847-384-1435

Select "done" below to submit your online Council Position Application.

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* 1. Please enter your name, email address and cell phone number.

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* 3. Please select the position for which you are applying.

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* 4. What year did you join ASSH?

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* 5. Primary employer:

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* 6. Board certification:

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* 7. Please describe past volunteer contributions you have made to ASSH COMMITTEES.

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* 8. Please indicate any ASSH COURSE CHAIR positions you have held in the past.

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* 9. Please indicate any ASSH INSTRUCTOR positions you have held in the past.

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* 10. Please indicate whether you have served on the AFSH BOARD in the past, and if so, indicate the position you held.

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* 11. Additional memberships:

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* 12. Please indicate your areas of medical interest/expertise that would enhance your Council board participation:

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* 13. Please describe any interests you have outside of medicine that could enhance your contributions to the Hand Society in general:

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* 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 1, 2011.

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* 15. Additional comments (optional):

* 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 1, 2011.