Ohio Association Medical Staff Services - Prospective Leadership Form

The Ohio Association Medical Staff Services is a thriving, growing, professional organization, with an ongoing need for talented, energetic leadership. Are you organized, enthusiastic, and ready to take on new challenges? Are you willing to work hard and make a commitment to your peers, as well as to your own professional growth? Being selected for an OAMSS leadership position (and there are many such opportunities, both inside and outside of the elected positions on the Board of Directors) can provide opportunities to "shine" in ways that your daily job may seldom offer.

Whether you have minutes or hours of potential "volunteer" time available each month, consider expanding your horizons by working with your State Association. Take a moment to complete this form, then forward it to any member of the OAMSS Board of Directors.

CANDIDATE: Please submit a current photo, resume, and brief biographical sketch to be used in election process, with Leadership Form

Professional Information

* First Name

* Last Name

* Organization

* Organization Address

* City

* State

* Zip Code

* Telephone

Fax

* Email Address

* Certifications

CPMSM
CPCS
CPHQ
OTHER:

If other, please specify

* Year Certified

* Education

If other, please specify

* Major

If other, please specify

* # of healthcare practitioners you are responsible for

* # of years in healthcare

* Leadership Interests Indicate those positions and areas of leadership you would be most interested in being considered for, along with a brief explanation.

President
President Elect
Secretary
Treasurer
Regional Representative
Website Administrator

* Leadership Interests - Explanation

* Career/Work Experience List past ten years only, beginning with most recent. Include title, organization and dates (or attached resume)

* OAMSS/NAMSS Activities Please indicate past and current OAMSS and NAMSS activities and board positions held in the past ten years:

* Special Honors / Awards Indicate any special honors or awards that you have received during the past ten years

* Goals Please submit your personal statement on goals you wish to achieve while serving on the OAMSS board

* Attach Current Photo

* Attach Resume

* Attach Brief Biographical Sketch

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