Fields marked with * are required.

CORD Committee/Taskforce Interest Form

Please complete the form below if you are interested in being appointed to a 2012-2013 Committee or Taskforce. 

If you have any questions please contact the CORD office at 888-444-2090 or cord@cordem.org.

 
First Name *
Middle Initial
Last Name *
Degree *
Institution *
Institution Address 1 *
Institution Address 2
Institution Address 3
Institution City *
Institution State *
Institution Zip *
Contact Email Address *
Phone
Curriculum Vitae
Please Indicate Your Current Position *
Chair
Program Director
Assistant/Associate Program Director
Clerkship Director
Program Coordinator
Resident
Other
Please list any previous or current CORD Committee or Task Force involvement/activities:
Please select the committee or taskforce that is your first choice: *
Please select the committee or taskforce that is your second choice:
Please select the committee or taskforce that is your third choice:
Are you interested in chairing or co-chairing a committee? *
Yes
No
If yes, which one(s)?
Do you have any additional comments to share with the BOD (ideas for new committees/task forces, etc)

Thank you for your interest!