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Committee Member Volunteer Application

We appreciate your interest in becoming more active in the Society. Before completing the form, here is some information you need to know.

You must be an American Society of Cytopathology member in good standing.

Volunteer forms may be submitted throughout the year, but appointments begin July. A committee appointment is for a two-year term and may be extended to one additional two-year term (total of four years). Committee terms begin at the conclusion of the Annual Scientific Meeting and continue through the next two Annual Scientific Meetings. For example, committee terms for 2010-2012 begin in November after the 2010 Annual Scientific Meeting and continue until the conclusion of the Meeting in November 2012.

Committees usually meet during the ASC Annual Scientific Meeting. While the ASC is unable to pay your travel costs to participate in committee meetings, we hope that you will find the experience personally and professionally rewarding.

Please understand we may not always be able to honor your request for a particular committee.

View Current ASC Committees and Charges

ASC Conflict of Interest Guidelines

If you are interested in serving on an ASC Committee, please complete this application:

*	First Name:
*	Last Name:
*	Credentials:
*	ASC Member ID Number:
*	Institution:
*	Job Title:
*	Email Address:
*	Please explain why you are interested in serving on the Committees selected below. Be sure to include any pertinent professional experience:
*	Current CV:
*	Please select one committee:
	Please select one committee:
	Please select one committee:
Conflict of Interest Disclosure for the Leadership of the American Society of Cytopathology
Conflict of interest is a circumstance or situation that is present when an individual's primary responsibility to provide unbiased and impartial decisions, judgments, or opinions on behalf of the ASC might be influenced by a secondary factor. Secondary factors may include influence by financial relationships, responsibilities on other Boards or in other organizations, or personal bias adversely affecting objective review. On an annual basis and updated as appropriate, each member of the Leadership of the ASC will complete a conflict of interest form and submit it to the ASC National Office. Such an affiliation or interest does not disqualify a member from being on a committee, but the Committee Members are aware of the relationship in printed or verbal form in advance any Committee discussions.
*Non-Financial Disclosures*
Do you have responsibilities and/or loyalties to other organization(s) or strong personal bias that may represent a conflict of interest related to discussion(s), deliberation(s) and/or decision(s) made on behalf of the ASC?
*	Non-financial Disclosure:	Yes No
*Financial Disclosures*
Do you or your immediate family have any of the following relationships with companies, device manufacturers or pharmaceutical companies involved in the field of cytopathology?
*	Financial Disclosures:	I have no financial disclosures I have the following financial disclosures
	Potential Conflicts:	Officer, board member, trustee, owner or employee of a company Owner of stock, stock options or bonds of a company Paid consultancy, scientific advisory committee membership or lecturer for a company in the last 12 months* Investigator for a company, including holding research grants from the company Holder of Patent
*Disclosure is not required for an honorarium paid by a university, hospital or medical society that extends the invitation for a lecture and has received unrestricted funding.
	Please list all affiliations and potential conflicts:
*	Today's Date:

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