FCACC Volunteer Service Application

The President of the Florida Chapter, American College of Cardiology appoints members to serve on committees and task forces for a term two-year term that may be renewed once for a total of four years of service. The Florida Chapter is interested in appointing Fellows, Assistant Fellows, Members, FITs, and Cardiovascular Team Members to committees.

Please complete the information below.

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Degrees *

e.g., MD, MBBS, PharmD, PA-C, ARNP, etc.

Type of Practice *

Name of Institution or Facility *

Subspecialty *

Adult Congenital & Pediatric Cardio-Oncology CVTeam (Nurse, PA-C, PharmD, etc.) Electrophysiology Geriatric Heart Failure & Transplant Imaging Interventional

Number of years ACC Member *

City *

Type of Membership *

FACC Cardiovascular Team Member FIT

Please select which committee(s) on which you'd like to serve

Advocacy Committee Cardio Oncology Cardiovascular Team Committee Education Committee FIT Committee International Committee Payer Relations & Health Care Economics Committee Quality of Care Committee Women Cardiologists (WIC) Committee

Please select up to three committees on which you'd like to serve. Indicate your interest by ranking them 1st, 2nd and 3rd. *

	1st Choice	2nd Choice	3rd Choice
Advocacy Committee
Cardiovascular Team Committee (Nurse, PA, PharmD, etc.)
Cardio-oncology Committee
FIT Committee
International Committee
Payer Relations & Health Care Economics Committee
Quality of Care Committee
Women Cardiologists (WIC) Committee

Committees meet by phone and in person at the FCACC Annual Meeting. All committee members are expected to attend the FCACC Annual Meeting. Please indicate if you are willing to be an active participant and attend meetings and conference calls.

Yes No