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* 1. I would like to be considered for:

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* 2. Name

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* 3. Date of ACAAI Fellowship

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* 4. Annual ACAAI Meetings attended in the last 10 years (by year)

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* 5. Have you presented an educational session (e.g., plenary session lecture, scientific workshop) or made a poster presentation at an ACAAI Annual Meeting within the last five years? If so, please list years and subjects.

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* 6. List any allergy-related awards or recognition received in the past 10 years.

Conflict of Interest Disclosure

Please answer the following questions or provide substantially the same information in some other form (e.g. by attaching a vita). If you have no information to list in response to a specific question, answer “None.”

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* 7. Positions in ACAAI
Please list all current or proposed relationships with ACAAI, including, but not limited to, positions currently held or sought in ACAAI.

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* 8. Relationship with Other Organizations/Entities
Please list any leadership role in, or other relationship with, any other corporation, association, society or foundation (e.g., board member, committee member, advisor, journal contributor).

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* 9. Employment
Please list any individual or entity for whom you are employed, about to be employed, or have been employed within the past three (3) years.

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* 10. Consultancies1
Please list any individual or entity for whom you2 are now providing, or are about to provide, consulting services, as well as any individual or entity for whom you provided such services, or by whom you were paid, during the past three (3) years.

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* 11. Royalties
Please list any individual or entity from whom you2 receive, or have received (in the past three (3) years) or are about to receive, royalties or similar payment.

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* 12. Ownership Interests1
Please list any ownership interests you2 hold in a commercial entity that reasonably may be anticipated to conflict with the interests of ACAAI.

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* 13. Honoraria
Please list any honoraria you2 have received within the past three (3) years, or expect to receive, of more than $25,000 per year or $50,000 over a three-year period.

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* 14. Research Funding - A
Please list any research funding that you2 are about to receive or have received within the past three (3) years.

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* 15. Research Funding - B
Please list any other research funding that you know has been received, or is about to be received, by others at your institution(s), which reasonably may be anticipated to conflict with the interests of ACAAI.

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* 16. Other Actual, Potential or Apparent Conflicts
Please list any other personal or professional position(s) or interest(s) you currently or are about to hold, or activities in which you are or are about to be engaged, which reasonably may be anticipated to conflict with the interests of ACAAI.

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* 17. Personal Statement
Please submit a personal statement describing your eligibility for, and interest in, serving on the ACAAI Board of Regents. The statement may address, among other things, the reasons you are interested in being a part of the College leadership; your ideas for improving various ACAAI programs, products, and services; and your “vision” for ACAAI in five years.

If you prefer to upload a personal statement in a Word doc or pdf file, please use the next section to upload one.

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* 18. Personal Statement

PDF, DOC, DOCX file types only.
Choose File

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* 19. Please upload your CV (maximum file size 16 MB).

PDF, DOC, DOCX file types only.
Choose File
ACAAI Conflict of Interest Leadership Policy
As approved by the ACAAI Board of Regents on November 10, 2016, Members may not serve on the Board of ACAAI within 18 months of having served on the Board of Directors of any other major specialty organization.

1 Only report those relationships or interests that reasonably involve the interests of ACAAI or allergy, asthma or immunology.

2 “You” includes you and anyone with whom you directly share income (e.g., a spouse, minor child, or business partner) as well as a third party whose interest may affect your decision-making (e.g., a sibling or adult child).
I understand the ACAAI strives to preserve its earned reputation of excellence in the fields of allergy, asthma, and immunology. To that end, applicants for positions on the Board of Regents must be of high moral, ethical, and professional standing. I represent and warrant that I do not now engage, and have not previously engaged, in any conduct, personally or professionally, which could adversely affect or bring discredit to the College.

I hereby request and authorize the evaluation and validation of my application. In furtherance of my application for an ACAAI Officer or Board of Regents position, I request and authorize any hospital, medical staff, medical organization, medical practice group, federal or state agency or individual who may have information (e.g., performance evaluations, medical records, patient records, committee reports) which are deemed relevant to my fitness to serve, to provide such information to ACAAI.

I hereby waive any claim for damages, or otherwise, that I may have against any hospital, medical staff, medical organization or individual which supplies information with respect to my application and/or the ACAAI, its officers, directors, members, and agents by reason of any act of omission or commission that they, or any of them, may take in good faith in connection with this application. I understand that the decision as to whether or not I qualify for a position within ACAAI, and whether I am nominated or elected to such position, will be determined solely and exclusively by ACAAI, and that its decisions are final.

I understand that there is a significant time commitment associated with serving as a College Officer or member of the Board of Regents, and I am ready, willing, and able to devote the time necessary to carry out my duties responsibly and completely.

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* 20. I understand and agree to the statements in the four paragraphs above.
In addition, I affirm that the information provided in this application is truthful and accurate.

Thank you for submitting your application for a position on the ACAAI Board of Regents.

An email will be sent to you within 2-5 business days at the email address provided above acknowledging receipt.

If you have any questions or concerns regarding this application, please contact Miriam Standish via email (miriamstandish@acaai.org) or via phone at 847-725-2299
 
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