Program Committee DEI Representative Self-Nomination Form - The Association for Surgical Education

Thank you for your interest in serving as the DEI Committee Representative to the Program Committee. Eligible members include DEI Committee members who are ASE members in good standing. The Representative will be nominated from the active, productive members of the committee using the below nomination form and should endorse the mission and values of the ASE. The Representative should also have the time and desire to participate in monthly Program Committee calls. Once the nomination process has concluded, the current Chair and Vice Chair will select the Representative for a term of 1 year.

Program Committee DEI Representative Nomination

Name*
First Last
Email*
Title*
Institution*
Are you an ASE member in good standing?*
- Yes
- No
Please describe your education and leadership experience in 150 words or less:*
Please describe your ASE membership and activities with the society in 150 words or less:*
Describe your goals/ideas for serving as the DEI representative to the Program Committee in 150 words or less:*