SCAI National Ambassador Application

SCAI National Ambassador

Thank you for your interest in becoming a SCAI National Ambassador. The goal of this program is to promote participation in SCAI amongst key stakeholders in their prospective countries. Active SCAI members from People's Republic of China, India, Egypt, Saudi Arabia, Turkey, and Vietnam may nominate themselves or others for a position.

Please review the position description before applying or nominating: National Ambassador Qualifications & Responsibilities

1. I have read the job description and I understand if selected, I will perform the duties listed. *This question is required.

2. If I am not selected to serve as Ambassador, I would like to be considered for the Ambassador-Elect position to assist the Ambassador. *This question is required.

3. First Name *This question is required.

4. Middle Initial

5. Last Name *This question is required.

6. Address *This question is required.

8. Email *This question is required.

9. Phone Number *This question is required.

10. Please write a brief (1-2 paragraphs) statement of interest.
*This question is required.

11. Please upload your CV. *This question is required.

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12. This position requires an investment of approximately 2 hours a week. I attest that I will be able to commit the necessary time. *This question is required.

13. Gender *This question is required.

Please enter an 'other' value for this selection.

14. Employment Setting *This question is required.

15. Is this institution affiliated with a Healthcare system?

16. Which one?

16. Professional Title *This question is required.

17. Years of SCAI Membership *This question is required.

18. Highest Degree of Education *This question is required.

19. Year Obtained *This question is required.

20. Previous/Current Offices held and Service on SCAI Society Committees, Boards, and/or Task Forces (list and give dates)

Space Cell	Office/Service Name	Start Date	End Date
SCAI Society Office/Service 1	SCAI Society Office/Service 1: Office/Service Name	SCAI Society Office/Service 1: Start Date	SCAI Society Office/Service 1: End Date
SCAI Society Office/Service 2	SCAI Society Office/Service 2: Office/Service Name	SCAI Society Office/Service 2: Start Date	SCAI Society Office/Service 2: End Date
SCAI Society Office/Service 3	SCAI Society Office/Service 3: Office/Service Name	SCAI Society Office/Service 3: Start Date	SCAI Society Office/Service 3: End Date
SCAI Society Office/Service 4	SCAI Society Office/Service 4: Office/Service Name	SCAI Society Office/Service 4: Start Date	SCAI Society Office/Service 4: End Date
SCAI Society Office/Service 5	SCAI Society Office/Service 5: Office/Service Name	SCAI Society Office/Service 5: Start Date	SCAI Society Office/Service 5: End Date
SCAI Society Office/Service 6	SCAI Society Office/Service 6: Office/Service Name	SCAI Society Office/Service 6: Start Date	SCAI Society Office/Service 6: End Date

21. Previous/Current Offices held and Service on Other Professional Committees (e.g. related organizations, other professional societies, government agencies, etc. List and provide dates)

Space Cell	Name of Organization	Office/Service Name	Start Date	End Date
Other Society Office/Service 1	Other Society Office/Service 1: Name of Organization	Other Society Office/Service 1: Office/Service Name	Other Society Office/Service 1: Start Date	Other Society Office/Service 1: End Date
Other Society Office/Service 2	Other Society Office/Service 2: Name of Organization	Other Society Office/Service 2: Office/Service Name	Other Society Office/Service 2: Start Date	Other Society Office/Service 2: End Date
Other Society Office/Service 3	Other Society Office/Service 3: Name of Organization	Other Society Office/Service 3: Office/Service Name	Other Society Office/Service 3: Start Date	Other Society Office/Service 3: End Date
Other Society Office/Service 4	Other Society Office/Service 4: Name of Organization	Other Society Office/Service 4: Office/Service Name	Other Society Office/Service 4: Start Date	Other Society Office/Service 4: End Date
Other Society Office/Service 5	Other Society Office/Service 5: Name of Organization	Other Society Office/Service 5: Office/Service Name	Other Society Office/Service 5: Start Date	Other Society Office/Service 5: End Date
Other Society Office/Service 6	Other Society Office/Service 6: Name of Organization	Other Society Office/Service 6: Office/Service Name	Other Society Office/Service 6: Start Date	Other Society Office/Service 6: End Date

22. If I am NOT selected to serve as Ambassador at this time, I would be interested in opportunities to serve on periodic Work Groups, Task Forces or Micro-projects.

(If you select Yes, you will receive an email with a request for additional information to be added to the pool)
*This question is required.

23. If you wish, attach any statements by society colleagues and/or others testifying to your previous experience.

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Please note many committees meet each year during the Annual Scientific Meeting and committee members attend this meeting at their own expense. Acceptance of appointment implies a commitment to attend.

Since there are only a very limited number of available ambassador appointments that may be made each year, it is impossible to meet all of the requests to serve. If not selected for the upcoming term, please consider submitting your name in the future or for the Physician & Clinician Service Pool where we draw for Work Groups, Task Forces and Micro-projects (see above)