Name

Email Address

Type of Committee (governance, advisory, accreditation, other):

Name and Location of Organization:

Brief Description of Purpose and Responsibilities of the Organization, and the Committee:

Why is the Involvement of Dr. Miller Important?

Number of meetings per year:

Amount of Travel Required:

Amount of homework/preparation between meetings:

Are funds provided for business class air travel and hotel accommodation for any required travel?

Is funding available for an honorarium for participation?