FCACC Volunteer Service Application

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 NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Degrees*
e.g., MD, MBBS, PharmD, PA-C, ARNP, etc.
Type of Practice*
Name of Institution or Facility*
Subspecialty*

Adult Congenital & PediatricCardio-OncologyCVTeam (Nurse, PA-C, PharmD, etc.)ElectrophysiologyGeriatricHeart Failure & TransplantImagingInterventional
Number of years ACC Member*
City*
Type of Membership*

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

Advocacy CommitteeCardio OncologyCardiovascular Team CommitteeEducation CommitteeFIT CommitteeInternational CommitteePayer Relations & Health Care Economics CommitteeQuality of Care CommitteeWomen 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
Early Career Committee
FIT Committee
FMA Delegation 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.

YesNo
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