EmailMe Form - Call for Candidates

EmailMeForm

Name *
First Last
Credentials (RCC, FRBMA, etc...)
Email *
Company *
Title
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Preferred Phone *
### - ### - ####
Special Skills: *
Fundraising
Personnel / HR
Finances / Accounting
Marketing / PR
Technology
Legal
Public Speaking
Six Sigma
Education Level: (check highest level of completed education) *
High School
Associate Degree
Undergraduate Degree
Graduate Degree
Doctorate (PhD, EdD, MD, JD)
Membership in RBMA: *
5 Consecutive Years
6 to 10 Consecutive Years
11 to 15 Consecutive Years
16 to 20 Consecutive Years
20+ Consecutive Years
Professional Volunteer Service to RBMA
Board Officer
(list year(s) served – this should be the actual year(s) served not number of year(s) served)
Board Member
(list year(s) served – this should be the actual year(s) served not number of year(s) served)
Committee/Task Force Chair
(list committee/task force and year(s) served)
Committee Member
(list committee/task force and year(s) served)
Employed by: *
Radiology Practice
Imaging Center
Hospital
University
Practice Management Company
Billing Service
Independent Consultant
Business Management/Financial Services Company
Other
Manage and Provide Services for: *

Number of Physicians

Number of Radiology Practices (PMC)

Number of Employees

Number of Procedures
DISCUSS THE EXPERIENCE YOU WOULD BRING TO RBMA’S BOARD: *
(Include RBMA and other association or society related experience)
DESCRIBE AN INITIATIVE OR FUTURE FOCUS YOU WOULD CHAMPION FORWARD FOR RBMA AS PART OF YOUR BOARD SERVICE: *
OTHER AFFILIATIONS OR BOARD SERVICE: *
Document Uploads
Letter of Reference *
Curriculum Vitae *
Agreement
By submitting this application, you are attesting that there is nothing in your past, such as conviction of a crime (other than a minor traffic offense) that has not been expunged, that would disqualify you from board service. If there is, please give the details , such as date place and offence or other event to Robert T. Still, RBMA Executive Director. Such information will not necessarily bar eligibility, but will be considered within the context of the entire application.

The information I have furnished in connection with my nomination is true and complete. I understand that if any misrepresentation has been made by me, any offer to become a board member may be withdrawn or my subsequent position may be terminated. I also hereby give the association the right to investigate my background and release the Association, and all persons supplying such information from liability relating in any way to the provision of such information. *
Yes
Signature
Clear

Number of Physicians
Number of Radiology Practices (PMC)
Number of Employees
Number of Procedures

Professional Volunteer Service to RBMA

Document Uploads

Agreement