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CMSAPUBLIC POLICY COMMITTEE

MEMBER APPLICATION

Please complete the form using the spaces below, then save, and email or fax to CMSA.

Date: Member Number:

Name: Credentials:

Applicant Information

Home Address:

Phone:E-Mail:

Employment Information

Employer: Can you accept calls at work? YesNo ( one)

WorkAddress: What hours are you available at work?

Phone:E-Mail:

Membership and Legislative Representation Information

Is Your CMSA Membership Current? YesNo ( one)Local CMSA Chapter Name:

Registered to vote at current home address: YesNo ( one)

Your Congressional District #: Represented by:

Additional Questions

  1. How did you learn about the Public Policy Committee?
  2. List reasons why you have decided to apply to this committee:
  1. List any CMSA councils or committees on which you are or have served:
  1. List any political or legislative activity in which you have volunteered(this includes volunteering for a political campaign, writing a letter to an elected official, etc.):
  1. List any elected offices you have held(this includes state/town/city council, school board and other local
    elected positions):
  1. Please include any additional information or comments here:

PUBLIC POLICY COMMITTEE MEMBER COMMITMENT

Below are the requirements for participating on the Public Policy Committee for the 2017-2018 year. Please check all activities in which you are able and willing to participate:

Attend Public Policy Summit in Washington, D.C. each year.

Mentor a chapter liaison to the Public Policy Committee.

Educate the public about CMSA & case management.

Participate in outreach to federal and state legislators in your area

Participate on Monthly Conference Calls.

Participate in discussions on topics relating to health policy

Work towards Creating Position Statements from CMSA as needed and as appropriate.

Support CMSA Public Policy Initiatives.

COMMITTEE TERM

The Committee members are appointed for terms ranging three to four years. The appointments are made by the Public Policy Committee Chair and Vice-Chair, withPresident’s approval and board ratification.

If this application to the CMSA Public Policy Committee is accepted by the leadership of the Committee and Board of Directors I acknowledge that my representation on the CMSA Public Policy Committee is in support of the mission and vision of the association. I will work to achieve the strategic objectives set forth by the leadership of CMSA to improve the industry and profession. My committee participation is neither dependent or in support of my personal political views or affiliation. I understand and will support CMSA as a bipartisan association with no support to any one candidate or political party

Signature: ______

Please return the completed application via emailto:CMSA
Attention:Shelly Greenwood

Email:Phone: (501) 673-1115

The leading membership association providing professional collaboration across the health care continuum.
Case Management Society of America | 6301 Ranch Drive | Little Rock, AR 72223 T 501.225.2229 F 501.221.9068 E