CS – Committee Interest Form Page | Converging Roads

General Information

Name Listing(Required)

Please list your name, title, and organization, including any credentials.
E.g.: Carla Falco, MD; President, Catholic Healthcare Professionals of Houston.

Basic committee member information (name, title, address) is required by the CMDA in order to apply for CME/CNE credits. Committee members are also included on our conference website. If you would prefer your name be listed differently on our conference website (or not at all), please check the appropriate box below.

Name Listing for Website

I would prefer an alternative name listing for external purposes on the conference website

I would prefer my name not be listed on the conference website

Website Name Listing

Please list your name, title, and organization as you would like to see it on any outward-facing conference materials, including the conference website.
e.g.: Robin Pierucci, MD, MA; Neonatologist and Medical Director

Email Address(Required)

Phone Number(Required)

Phone Type

Cell

Home

Office

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

What parish do you attend?(Required)

CME/CNE Application Details

Professional Title

If your professional title is different from the above Name Listing, please list it here.

Institutional Affiliation

If your institutional affiliation/employer is not included in your name listing above, please include it here.

Institutional Address(Required)

CMDA Disclosure Form(Required)

Accepted file types: doc, docx, Max. file size: 50 MB.

Please use the link at the top of this page to download the Disclosure Form from the CMDA and complete ONLY the highlighted portions. This form is required by the CMDA for application and approval of CME/CNE credits. It MUST be submitted as a Word document; PDFs WILL NOT be accepted.

Conference Involvement

For which conference are you serving on the committee?(Required)

Generally, when would you be available for committee calls?(Required)

Committee calls are typically 30-45 min and occur monthly during the 4-6 months leading up to a conference. Final scheduling details will be shared when all committee members' availability has been determined.

Additional Scheduling Notes

	Late Morning	Lunch	Early Afternoon	Late Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday

COMMITTEE
INFORMATION FORM

General Information

CME/CNE Application Details

Conference Involvement

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COMMITTEEINFORMATION FORM

General Information

CME/CNE Application Details

Conference Involvement

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