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Committees Interest Form

Are you interested in serving on a RPA committee? If so please submit the following application for consideration. Thank you for your submission.

Full Name:  
Job Title:  
Telephone:  (include area code) 
Fax:  (include area code) 
E-mail:  
Address:  
City:  
State:  
Zip Code:  

The following committees have vacancies annually. Please indicate your first three choices my marking "1", "2," and "3" in the corresponding boxes.

Policy Committees
Clinical Practice Committee
Government Affairs Committee
Health Care Payment Committee
Quality, Safety & Accountability Committee

Administrative/Operational Committees
Finance Committee
Nominating Committee
Practice Managers Committee
Program Committee

  RPA Activities
National Participation:
Position:
Years Served:
   
Regional Participation:
Position:
Years Served:

Other RPA Activities:

Other Professional Memberships/ offices/positions (include dates):

List other activities such as publications, honors, awards, special projects:

Area of Expertise (state your qualifications or special expertise for serving on the committee you have identified):

I hereby declare that the information provided in this application is complete and true to the best of my belief.

Signature:   
Date: