MDACC Volunteer Service Application

MDACC Volunteer Service Application
The President of the Maryland Chapter, American College of Cardiology appoints members to serve on committees and task forces for a term two-year term that may be renewed once for a total of four years of service. The Maryland Chapter is interested in appointing Fellows, Assistant Fellows, Members, FITs, and Cardiovascular Team Members to committees.

Please complete the information below.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Degrees*
e.g., MD, MBBS, PharmD, PA-C, ARNP, etc.
Type of Practice
Name of Institution or Facility*
Number of years ACC Member*
City*
Type of Membership*

FACCCardiovascular Team Member (NP, RN, PA, PharmD, etc.)FIT
Sub-specialty:*

Adult Congenital & PediatricCardio-OncologyCVTeamElectrophysiologyGeriatricHeart Failure & TransplantImagingInterventional
Please rank the committee(s) in order of which you'd most like to serve to least like to serve*
Committees meet by phone and in person at the MACCS Meeting. All committee members are expected to attend the MACCS Meeting. Please indicate if you are willing to be an active participant and attend meetings and conference calls.*

YesNo
Should be Empty: