Review Committee - EM Nomination Form

Last Name*

First Name*

Credentials

Medical Degree (MD/DO), Advanced Degrees

Email Address

Phone Number

City, State of Residence

Are you actively participating in ABEM Continuing Certification?

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Current Program Director Role

If applicable, please list your current residency program's name/location and dates of service.

Previous Program Director Roles

List any previous program director experiences including residency program name/location, dates of service, and number of years served.

Statement of Interest

Please provide a brief statement of interest in serving on the ACGME Review Committee for Emergency Medicine. Why do you want this opportunity?

Send me a copy of my responses