TEXAS SOCIETY OF MEDICAL ASSISTANTS AAMA DELEGATE
& ALTERNATE NOMINATION CONSENT FORM

*are Required Fields.

Delegate And Alternate Nomination And Consent Form
I wish to be consider nominated and do hereby consent to serve if elected as:
I assert that I will fulfill my duties as stated below. At this current time there is nothing preventing me from serving in this honored position (i.e. good health, personal affairs, job obligations). I understand that should I not be able to fulfill my role as a delegate and if I have incurred expenses, it is my responsibility to seek out refund of those expenses from appropriate vendor and that TSMA is not responsible for those expenses incurred. If I have received any reimbursements from TSMA for conference expenses including travel and registration, that I will be responsible for repayment to TSMA.
Please type your full name to represent your signature.

I understand that my duties as a delegate/alternate delegate will include (Please check each one.)

Please check all.
Leadership Roles: (includes offices held, chairmanships, committee memberships)