Committee Volunteer Form

Thank You for your interest in supporting your medical profession by volunteering to serve on a MSSNY Committee. Committee participation is an important role since committees address the issues facing physicians and the medical profession. Please visit our website for a description of all committees: MSSNY website.

You must be current in your MSSNY dues to be considered for any committee position. Please complete the form below, indicating your two preferred committees. If a committee you are interested in is not shown, it means that the committee does not need new members for 2026. All forms must be submitted no later than Tuesday, September 30, by 4:00 PM. Any form received after that deadline will not be considered. MSSNY’s President-Elect will be reviewing all applications early in 2026, and all approved appointments will be presented to MSSNY’s Council at either their March or June meeting. Once approved, your appointment will begin immediately. Please note that in order for your appointment to be submitted for approval, your 2026 MSSNY dues must be submitted by March 2, 2026.

Name*

First NameLast NameSuffix

Specialty*

Email*

example@example.com

Mobile Number*

Please enter a valid phone number.

Address*

Street Address

Street Addre

CityState

Zip Code

Please Select Your County*

Are you currently serving on a committee(s)? If so, please select all applicable committees from the list below.

To select multiple options, please hold the CTRL key while making your selections.

Please select two committees for which you would like to volunteer. For your first committee preference, please select from the list below:*

Select Second Committee Preference*

Why are you interested in serving on these committees?