Please complete this brief questionnaire to assist the IAMRA Board in finalizing their appointments for IAMRA committee service in FY 2027 (May 2026-April 2027). Should you have any questions, you may contact Ms. Sarah Heermans, Director of Operations at sheermans@iamra.com.

1.Full Name (include credentials, i.e., MD, DO, PhD, etc):

2.Organization with which you are associated:

3.Relationship, i.e., Physician Member, Public Member, Staff or Other (please specify):

4.Preferred email address for all IAMRA communications:

5.Please list prior IAMRA service, if applicable:

6.Please provide a short statement outlining how you meet the membership criteria for this Committee (see attached Charter):

Thank you for completing this questionnaire!