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Application for Committee Membership or Liaison Status

Instructions:
1.  Name
Prefix: (eg. Dr., Mr., Ms.)
First Name:
Middle Name or Initial:
Last Name:
Suffix: (eg. Jr, II)
Designation: (eg. MD, PhD, CBET)
Title:
2.  Business Address
Company:
Address Line 1:
Address Line 2:
City:
State or Province:
Zip/Postal Code:
Country:
(if US leave blank)
Phone: Country Code (if outside US): Number:
Fax: Country Code (if outside US): Number:
Email:
3.  Select an Interest Category
Select One:  See Descriptions
4.  AAMI Membership
AAMI Member Type: Individual Institutional Corporate Not a Member
5.  Committee You are Applying To
Contact standards@aami.org regarding nomination process for committees not listed below.
Select One:
6.  Committee Status
I am NOT currently on this committee.
I am currently on this committee and am reapplying to change my committee position.
I am currently on this committee and am reapplying to change who I represent.
I am currently on this committee and am reapplying to represent additional organizations.
(include organization currently represented as well as new organizations in item #8)
7.  Position Requested
Select One:
See Descriptions 		Primary Voting
Alternate Voting
Committee Liaison
AAMI Organizational Member Liaison
7a. Qualifications - Direct Material Interest:
(Primary or Alternate Voting only).

Also complete 7b. 		Do you/the organization you represent have a direct and material interest in the work of the committee?
Yes (briefly describe, e.g., “my company manufactures products that are subject to the committee’s standards” or “ I use the devices standardized by the committee in my medical practice”)


No
7b. Other Qualifications:
(Primary or Alternate Voting only).

Also Complete 7a. 		Option 1: Email your CV/resume separately to standards@aami.org.
(Application will not be processed until CV/resume is received.  One copy is sufficient if applying to several committees.)
OR
Option 2: Briefly describe your other qualifications for membership on the committee, including relevant education and experience, in the box provided.
8.  Disclosure Information   See Description
8A.  Do / will you represent one or more manufacturers or institutions on the committee of application? 
No: If no, click here to go to item 8B.
Yes: If yes, identify the manufacturer and/or institution and its AAMI membership status below.  If representing company or institution other than employer, send Letter of Nomination from company/institution with your application.  Committee liaisons should identify the sponsoring institution here and full committee name in #8B.
Manufacturer or institution represented:
Parent Company:
(if any)
AAMI Mbr/Fee Payer:
(company or its parent) 		Yes   No (If you check "NO", see NOTE)
8B.  If you do not represent manufacturers or institutions, who do you represent?
a.  Myself (Independent Expert)
b.  Other Fill in complete name; do not use acronyms.  Committee liaisons:  Please include alphanumeric designation(s), if any, and committee name(s); you can represent more than one committee to the AAMI committee.
9.  Conflict of Interest (requests for Voting Membership only)
The Disclosure Section (#8) requested that you identify the company or organization that you plan to represent on a committee.  If you have relationships that could be perceived as a conflict of interest with any OTHER companies (i.e., companies not identified in the Disclosure Section), identify the companies and briefly describe the nature of the relationship / potential conflict of interest here.  (Such relationships do not necessarily disqualify an applicant from an independent voting membership on a committee.)  If no conflict of interest, please so state.
10.  Submission Options
Select the PREVIEW button below.  You will have the option to edit, SUBMIT by email, or you can print out the preview page and fax or mail the preview page to the AAMI Standards Department.