ABCD Committee Position Application

First Name ^*

Last Name ^*

Primary Email ^*

Other Email

GMC Number ^*

GMC Expiry Date ^*

Position ^*

Position (other)

Specialism ^*

What is your position within your organisation

Supporting information

What is your current role(s) and relevant experience of/interests in diabetes ^*

What is your involvement in ABCD activities to date ^*

Please tell us why you want to stand for election and what you feel you can contribute to the ABCD Committee ^*

Application endorsers

Please provide the full name and of two person endorsing your application.

Please note:

Your endorser must be a member of ABCD.
You are required to seek permission from the endorsers and ensure they are happy to support your application before completing this section.
Endorsers will be contacted to confirm they are happy to endorse your application upon receipt of your submission.

Name of Endorser 1 ^*

Email Endorser 1 ^*

Name of Endorser 2 ^*

Email Endorser 2 ^*

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