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IMTA Committee Registration Form

IMTA Committee Registration Form

IMTA Committee Registration Form

This form is used to identify potential volunteers for IMTA committees.

Step 1 of 4 – General Information

25%

Name(Required)

First Middle Last

Title

Organization(Required)

Language(s) Spoken(Required)

Arabic

English

French

Hindi

Mandarin

Portuguese

Indonesian

Spanish

Standard German

Other

CONTACT INFORMATION

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Website

Phone(Required)

Skype

COMMITTEE INFORMATION

Please select the committee(s) you are interested in joining.

Credentialing and Accreditation

Education

Are you willing to lead a committee?

Yes

No

ADDITIONAL INFORMATION

Volunteer Experience

Tell us about your background and give us an idea of the experience you have volunteering in organizations.

Leadership Experience

Tell us about any roles that you have head leading committees or organizational activities .

Are you currently volunteering with any other organization(s)?(Required)

Which organization do you serve as a volunteer and in which position(s)?(Required)

Do you believe this would pose any potential conflict of interest?(Required)

Please describe

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