Endocrine Clubs Network-Survey

* indicates a required field.

Club Information

*Official Name of Club:

City or geographic area the club serves:

Year the club was established:

Number of members:

Average times per year the club meets:

Average number of attendees at each meeting:

Club Mission Statement:

Website:

Main Contact Information

*First name:

Middle name:

*Last name:

Title:

*Address One:

Address Two:

*City:

*State/Province: ...if Other:

*Zip/Postal Code:

Phone:

Fax:

*Email:

Club Administrative Information

Please let us know how The Endocrine Society could better server your club:

(Ctr-Click or Apple-Click to select multiple)

If other:

Does your club have a Board of Directors or governing body (e.g. President, Vice President, etc)? Yes
No

If yes, please provide us with either a group email list for your board or addresses for each of your officers:

Has your club adopted bylaws? Yes
No

How is your club managed administratively? (A local medical society or other medical organization?)

How is your club supported financially? (i.e. membership dues, industry support?)

One of our representatives would like to contact you or another person in your group to discuss your programs and how we can be of assistance? Please give us the name and telephone number:

Club Roster

We are currently attempting to establish a comprehensive clubs database. If possible, we would like to incorporate your membership roster into this database. Could you please upload a copy of your membership roster as either a MS Word (.doc) file or a comma delimitted (.csv) file?

Select file: