Published on Physicians for a National Health Program (http://www.pnhp.org)

PNHP Activist Survey

Please take a moment to tell us a little more about yourself and your interests.

Name (first and last):

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

E-mail Address:

Medical Specialty:

Place(s) of Work / Position(s):

Interests / Expertise (Medical/Policy):

I can do public speaking in my area:

1-2 times per month

3-4 times per year

as needed

I would like to give presentations:

At Grand Rounds

To local/community groups

To business audiences

I am willing to do media work:

Write letters to the editor or op-eds

Contact local radio, TV and newspapers about specific events

Additional information:

I will work in developing/expanding a PNHP chapter, please give my information to the local chapter

I am willing to recruit my colleagues to join PNHP, please send me membership brochures

Attach CV:

(txt, rtf, odf, pdf, and doc file formats only - 1MB size limit)

Source URL (retrieved on Thursday, May 24, 2012): http://www.pnhp.org/activist-survey