GCEP Committee Interest Form

Name

Years as Georgia Chapter Member

E-mail Address*

Mailing Address  

Telephone (Provide all and check preferred number)

Business

Home 

Cellular 

Voice Mail

I am interested in becoming active with the following committees (choose all that apply):

Disaster

Legislative

Reimbursement

Medicare

EMS

Education 

Pediatrics

Website

I may also interested in:

a seat on the Georgia ACEP Board of Directors

a seat as a Georgia Chapter ACEP Councilor

a seat as a Georgia Chapter ACEP Alternate Councilor

a seat as an Officer of the Board

Please indicate what qualities or experience that you would bring to this Georgia Chapter position, including previous service to the Chapter, committee service, National ACEP service, and/or applicable professional experience.