[Use to submit your candidacy]
Deadline for nominations is November 4, 2016.
Undergraduate College Degree
Doctorate (e.g., PhD, EdD, MD, JD)
3 to 5 consecutive years
6 to 10 consecutive years
11 to 15 consecutive years
16 to 20 consecutive years
20+ consecutive years
Practice Management Company
Business Management/Financial Services Company
# of Physicians
# Radiology Practices (if employed by a PMC)
# of Employees
# of Procedures
By submitting this application, you are attesting there is nothing in your past, such as conviction of a crime (other than a minor traffic offence) that has not been expunged, that would disqualify you from Board service. If so, please provide the details, such as the date, place and offense or other event to Michael Mabry at email@example.com or 703.621.3359. Such information will not necessarily bar eligibility, but will be considered within the context of the entire application, at the sole discretion of the RBMA Nominating Committee.
The information I have furnished in connection with my nomination is true and complete. I understand that if any misrepresentation has been made by me, any offer to become a Board member may be withdrawn or my subsequent position may be terminated. I also hereby give the Association the right to investigate my background and release the Association, and all persons supplying such information from liability relating in any way to the provision of such information.
By typing your name and hitting “Submit” you acknowledge and agree with the rules set forth.
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