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