Skip to content
Health Policy and Advocacy Group - HPAG Application
1.
Name and Credentials
2.
ACS Member ID Number (if applicable/known)
3.
Institution/Organization
4.
Business Address
5.
City
6.
State
7.
Country
8.
Zip Code
9.
Email
10.
Phone Number
11.
Specialty
Colon-Rectal Surgery
Obstetrics and Gynecology
Neurological Surgery
Oral-Maxillofacial Surgery
Ophthalmic Surgery
Orthopedic Surgery
Pediatric Surgery
Plastic and Reconstructive Surgery
General Surgery
Cardiothoracic Surgery
Urological Surgery
Vascular Surgery
Other (please specify)
12.
What other ACS committees are you applying to? (you may apply up to 2)
13.
Please list other ACS Committee(s) you currently serve on
14.
Describe why you want to serve as a member of HPAG
15.
Please send your CV or bio sketch to cbloom@facs.org
I have completed this step