ASMBS State Chapter Leadership Request Form
For use by State Chapter Presidents, Directors, or Administrators to request ASMBS representation at chapter meetings.
State Chapter Submitting the Application
*
Name
First Name
Last Name
Email
example@example.com
State Chapter Meeting Dates
*
Is this State Chapter Meeting In-Person or a Virtual Meeting?
*
In-Person
Virtual
Is funding available for ASMBS Leadership to attend?
*
Yes
No
If funding is available for ASMBS Leadership to attend, please provide the parameters
Which ASMBS Leadership is needed for participation? Check all that apply.
ASMBS President, Richard Peterson, MD MPH FACS FASMBS DABS-FPMBS
ASMBS AMA Representative, John Scott, MD FACS DABOM FASMBS DABS-FPMBS
ASMBS CEO, Diane Enos, EdD, MPH RDN CAE FAND
What is required of the person attending?
*
Keynote, EDU Presentation, Etc.
Please provide any additional details here.
Is it desired for ASMBS Executive Leadership to be present or set-up a table to support membership or other questions for members?
*
Yes
No
Submit Request
Should be Empty: