Committee Assignment Acceptance

Date

Member's Name

Member's Email

Committee/Task Force/Workgroup Name

By submitting this form:

• You agree to serve ASGE in this capacity (see accompanying documentation for details of your appointment).
• Or you may decline the appointment.

I conclude that, to the best of my knowledge,

(Please select one of the following)

NO, I am unable to serve at this time and DECLINE the appointment.

YES, I am able to serve.

For additional questions, please contact: James Janssen, Governance Manager
American Society for Gastrointestinal Endoscopy
Email – jjanssen@asge.org

3300 Woodcreek Drive
Downers Grove, IL 60515