Florida Society of Medical Assistants

CONSENT TO SERVE FORM

I __________________ hereby give permission for my name to be placed in nomination for the

office of _______________________ of the Florida Society.

_________________                __________________
    signature                                                           date

...........................................................................................

I ____________________hereby  offer to serve FSMA in the following capacity:

Committee Chairman ____

Committee Member _____

The following committee(s) interest me and are ranked in order of my personal preference:

_________________

_________________

_________________

_________________

Additional comments ________________________________________________

__________________________________________________________________

________________________    __________
        signed                             date