Candidate Information Form - Exam Committee 2020

The American Board of Internal Medicine (ABIM) seeks candidates to serve on a variety of Exam Committees as part of our governance structure.

Please complete this form to nominate a candidate, or to self-nominate, for an ABIM Exam Committee.

*** You will have the ability to save this form and continue at later time. You must click on the gray bar at the bottom of the page to add your email. You will then be sent a link to continue this form where you left off. Otherwise you will be forced to start from the beginning. ***

1. Please select one of the following: *This question is required.

Please tell us who nominated you:

Nominator's name

Please select the society that nominated you. *This question is required.

Please provide the following information about the nominee:

First Name *This question is required.

M.I.

Last Name *This question is required.

Suffix

Title

Employer

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

ABIM ID (if known or applicable) This question requires a valid number format.

Letter of support:
In approximately 200-300 words, please share why your colleague should be considered as a member of an ABIM Exam Committee. ABIM's mission is to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care. *This question is required.

Click on the "Next" button to complete your candidate nomination.

Please provide the following information about yourself:

First Name *This question is required.

M.I.

Last Name *This question is required.

Suffix

Title

Employer

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

First Name of Assistant

Last Name of Assistant

Phone Number of Assistant

Email Address of Assistant This question requires a valid email address.

ABIM ID (if known or applicable)

I am applying for service on the following Exam Committee (Select one): *This question is required.

If you currently or previously served on a governance entity for ABIM or the ABIM Foundation, please indicate on which board(s)/committee(s) you served (Skip this question if you are new to service on an ABIM governance entity):

Candidate Information Form - Exam Committee 2020

Contact Information