Application for OAASC Committee Membership

Please complete the following information.
Name
Title
Facility
Address
City State Zip
Phone
Fax
Email
Internet URL
Please indicate below the committee(s) for which you would like to be considered,
even if you’ve served on the committee previously.
  Government Affairs Committee Education Committee
  Reimbursement Committee Membership Committee
  Quality and Clinical Outcomes Committee Finance Committee
Your Qualifications for this Appointment:
 
   - denotes required fields