Name *
(i.e. MD, PhD, etc.)
Physical Home Address
Physical Home Address
Optional unless you are on the Board of Directors.
Work Address *
Work Address
Required of all board members.
Name of Assistant
Name of Assistant
(If you would rather that we coordinate with your assistant.)
Please list which fields or subjects are of interest to you (if not listed on your CV).
If there are any meetings that you attend often, please list the name of the meeting and month that it takes place.
Please list any accomplishments you've made towards expanding scientific knowledge and/or applications.