Please answer the following questions to the best of your knowledge and click the Send button when you are ready.

What previous committees have you served on for SSR or other organizations?

SSR Committee of Interest
(Select multiple committees of interest by holding down the CTRL key while selecting)

ACR Representatives AD Hoc Corporate Liaison Committee Ad Hoc MOC/SAM Committee Audit Committee Electronic Communications Committee Finance Committee Historian Historian (Assistant) Membership Committee Nominating Committee Practice Guidelines and Technical Standards Committee Program Committee Research Committee Residency and Fellowship Education Committee Rules Committee Socioeconomic Affairs Committee SSR Representatives to Other Societies Strategic Planning Committee

Previous related experience or knowledge in this area.

Much SSR Committee work is done electronically through email, do you have email access on a daily basis?

YesNo If yes, enter your email:

Tell us about yourself.

What is your name?

Are you a member of SSR?

YesNo

How can we contact you?

Other comments/questions?