360 Degrees of Radiology Resources
The leading professional organization for radiology business management professionals in any radiology setting.

Call For Nominations

[Use to submit your candidacy]

Deadline for nominations is November 4, 2016.

Questionnaire

First Name:
Last Name:
Credentials (e.g. MD, RT, RCC):
Title:
Employer:
Address:
City:
State:
Zip Code:
Day Phone: ( ) -
Evening Phone: ( ) -
E-mail Address:
   
Special Skills:

Fundraising
Personnel/Human Resources
Finances/Accounting
Marketing
Public Relations
Technology
Legal
Public Speaking
Six Sigma
Other:

   
Education Level (check highest level of completed education):

High School
Associate Degree
Undergraduate College Degree
Graduate Degree
Doctorate (e.g., PhD, EdD, MD, JD)

   
Membership in RBMA:
Board Candidates must have been an RBMA member (Active or Corporate) for at least three (3) years

3 to 5 consecutive years
6 to 10 consecutive years
11 to 15 consecutive years
16 to 20 consecutive years
20+ consecutive years

   
Professional Volunteer Service to RBMA:  
Board Officer (list year(s) served -- this should be the actual year(s) served not number of year(s) served.):
Board Member (list year(s) served -- this should be the actual year(s) served not number of year(s) served.):
Committee/Task Force Chair/Chapter President (list committee/task force and year(s) served):
Board Candidates must have served on an RBMA committee/task force or state chapter within the last five (5) years
Committee Member (list committee/task force and year(s) served):
Board Candidates must have served on an RBMA committee/task force or state chapter within the last five (5) years
   
Employment Information:  
Employed by:

Radiology Practice
Imaging Center
Hospital
University
Practice Management Company
Billing Service
Independent Consultant
Business Management/Financial Services Company
Other:

   
Manage and Provide Services for:

# of Physicians
# Radiology Practices (if employed by a PMC)
# of Employees
# of Procedures

   
Discuss the experience you would bring to RBMA's Board (include RBMA and other association or society related experience):
   
Other Affiliations:
   
Other Board Service:
   
Committee Service:
   
Curriculum Vitae/Letter of Reference:
Candidates for the board must provide their CV and a letter of recommendation (if self-nominated). If the candidate is nominated by someone else, then that serves as the letter of recommendation and no additional letter is necessary. Failure to include any of these documents constitutes an incomplete application which may result in a delay or omission from consideration.

Curriculum Vitae:
Letter of Reference:

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 jessica.struve@rbma.org 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.


Candidate’s Name

By typing your name and hitting “Submit” you acknowledge and agree with the rules set forth.


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