Puerto Rico Chapter of the American College of Emergency Physicians

2026 Puerto Rico ACEP Chapter - Junta Directiva Interest Form

¡Gracias por su interés en formar parte de la Junta Directiva del Capítulo de Puerto Rico ACEP! Por favor, complete este formulario para someter su candidatura. Toda la información será evaluada por el comité correspondiente.

Member Information

Name(Required)

First Last Credentials (MD, DO, MPH)

Email(Required)

Enter Email Confirm Email

Phone(Required)

Este número no será compartido con ninguna persona fuera de la Junta Directiva del Capítulo de ACEP Puerto Rico.

Are you a member of the Puerto Rico ACEP Chapter?(Required)

Please provide your ACEP Membership ID A# (if applicable)

Are you a Resident or Fellow?(Required)

What hospital are you affiliated with?(Required)

Puerto Rico ACEP Chapter Board Positions

What role are you interested in or running for?(Required)

Brief Description of why you feel you would be a good candidate for this role? ((Required)

(250 words max)

Headshot(Required)

Please upload a headshot. Accepted file types: jpg, jpeg, gif, Max. file size: 50 MB.

Max. file size: 50 MB.

Do you have any Conflict of Interests to Disclose?(Required)

Additional Comments or Notes

Board of Directors

2026 Puerto Rico ACEP Chapter - Junta Directiva Interest Form

Member Information

Puerto Rico ACEP Chapter Board Positions