PSAM Call for Committees 2025

PSAM

Help Shape the Future of PSAM: Apply for a Committee!
Name*

First NameLast Name
Credentials*
Ex. MD, DO, Pharma, etc.
Work Information*

Name of Facility/Organization

Address

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Preferred Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a Current Member of PSAM*

YesNo
If not, we’d love to have you! Membership is required to serve on a PSAM committee. Click Here to Join Today!
Committee(s) of Interest (please check all that apply)*

Public PolicyEducationPSAM ReviewAdvance Practice Providers (*Must be an APP to Join this Committee)
Please rank your interest in serving on "Public Policy" Committee from 1 to 4, with 1 being the most interested.
Please rank your interest in serving on "Education" Committee from 1 to 4, with 1 being the most interested.
Please rank your interest in serving on "PSAM Review" Committee from 1 to 4, with 1 being the most interested.
Please rank your interest in serving on "Advance Practice Providers" Committee from 1 to 4, with 1 being the most interested.
Relevant Experience - describe any previous committee, board, leadership, or advocacy experience. *
Personal Statement - state why you interested in serving on this/these committee(s)? What perspectives or skills would you bring? *
Additional Comments- Is there anything else you would like PSAM to consider regarding your application?
I understand that committee appointments are voluntary and may involve a time commitment.*

YesNo
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