Pilot Diversity Talent Bank Form

Complete this form to be added to the AGA Talent Bank Database. The database will be used by conference organizers and other program planners to identify diverse speakers, authors, mentors, faculty, and others with specific expertise for volunteer opportunities.

First Name*

Last Name*

Title*

Current Organization*

Email *

Gender*

Other

Address *

Address Line 2

City*

State / Province / Region*

Postal / Zip Code*

Country

Education*

Training institution*

Year graduated from fellowship*

Areas of expertise (check all that apply)

Common Gastrointestinal Complaints Checkbox

Common Gastrointestinal Complaints

Diagnostic and Therapeutic Modalities Checkbox

Diagnostic and Therapeutic Modalities

Esophagus Checkbox

Esophagus

Gallbladder and Pancreas Checkbox

Gallbladder and Pancreas

GI Issues Specific to Special Populations Checkbox

GI Issues Specific to Special Populations

Intestinal disorders Checkbox

Intestinal disorders

Liver Checkbox

Liver

Nutrition and Obesity Checkbox

Nutrition and Obesity

Policy/ Insurance Issues Checkbox

Policy/ Insurance Issues

Stomach and Duodenum Checkbox

Stomach and Duodenum

Miscellaneous Topics Checkbox

Miscellaneous Topics

Other

Leadership and Professional Development Competencies – First Selection*

Leadership and Professional Development Competencies – Second Selection*

Leadership and Professional Development Competencies – Third Selection*

Identify the areas where the majority of your time is spent

Note: Combined percentages should add up to 100%

Research Clinical Activity (% of time spent) *

Research Basic/Translational (% of time spent) *

Patient Care (% of time spent)*

Administration (% of time spent) *

Teaching (% of time spent)*

Industry (% of time spent)*

Other (% of time spent)

If other, please elaborate.

Headshot*

CV*

Feedback (for committee use only)

This field should be left blank

Pilot Diversity Talent Bank Form

4930 Del Ray Avenue, Bethesda, MD
20814

301-654-2055

Connect with AGA

4930 Del Ray Avenue, Bethesda, MD
20814

301-654-2055

Connect with AGA

Pilot Diversity Talent Bank Form

4930 Del Ray Avenue, Bethesda, MD20814301-654-2055

Connect with AGA

4930 Del Ray Avenue, Bethesda, MD20814301-654-2055

Connect with AGA

4930 Del Ray Avenue, Bethesda, MD
20814

301-654-2055

4930 Del Ray Avenue, Bethesda, MD
20814

301-654-2055