New Network Initial Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
When did you hold your discovery meeting?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many people attended and indicated interest in joining a new network in your area?
State your network will be located in:
*
What geographical areas do you plan to cover with your new AVA network?
*
What do you want to call your new network?
*
Please enter the following for each your potential network officers: name, email, employer and the positions they will fill for the network. You must have a minimum of two officers. All network leaders will be required to maintain a current AVA membership.
*
How do you plan to drive AVA membership and AVA Scientific Meeting attendance through your network? Do you have a strategy for encouraging scientific presentations to conference or JAVA, or written submissions to Intrarvascular Quarterly?
*
Which vendors/companies are active in your area, and are there any you would like help with in connecting to your network?
*
Would you like assistance with your network logo graphical design?
*
By checking this box I indicate that I understand that if my new network's initial application is accepted, the new network leaders will be responsible for setting up the legal entity with the IRS and for setting up a bank account for the entity.
I understand
Submit
Should be Empty: