2012 General Assembly

Please type the date(s) that you are available to serve as the Physician of the Day on the form below the calendar. This year the ISMA is covering February. Also, please fill out the bottom portion of the form.  You will receive a confirmation letter if the day is available. 
E-mail Ambre Marr if you have any questions.

February 2012
Sun.	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.
			1	2 No Session	3 No Session	4
5	6	7 Taken	8 Taken	9 Taken	10	11
12	13 Taken	14 Taken	15 Taken	16 Taken	17	18
19	20 Taken	21 Taken	22 Taken	23 Taken	24	25
26	27	28 Taken	29 Taken

		Please list the date(s) you are willing to serve in order of preference in the box below (ex: 1st choice 2/10, etc.):
		I am willing to serve more than one day.
Name		A value is required.Minimum number of characters not met.Exceeded maximum number of characters.
Address
City
Zip
Office Phone
Home Phone
Office  Fax
E-mail		A value is required.
Malpractice carrier
I am willing to serve as a back-up for unexpected cancellations and may be available on short notice.
The best day(s) of the week for me:
Don't put anything in the following field: