SZMSA ZMAC Member-at-large

Please complete the form below to submit your expression of interest

Full Name

First Name

Last Name

AMA #

Location of practice

Specialty

Conflict of interest: SZMSA representatives are asked to conduct themselves ethically and with integrity, honesty, and diligence in performing their duties. Please disclose any position, role, and/or situation in which there is a real or potential for conflict of interest that could interfere or be perceived to interfere with your judgment in pursuing the best interests of the SZMSA (i.e., leadership position with the AMA, AHS, CPSA, etc.).

Up to 250 words highlighting how your experience and expertise will contribute to the role