6 Revised October 2020 Copyright 2009 Association of Surgical Technologists APPENDIX A APPLICATION FOR ASTSA STUDENT REPRESENTATIVE CURRICULUM VITAE *All information must be completed. Incomplete documents will not be accepted. CANDIDATE INFORMATION: Student Name: ______________________________ Anticipated Graduation Date: __________ Street Address: ________________________________________________________________ City: ______________________________ State: _________ Zip Code: _________________ Phone: ____________________________ Email: ___________________________________ AST Member #: _____________________ Expiration Date: ___________________________ PROGRAM INFORMATION: Program Name: ________________________________________________________________ Street Address: ________________________________________________________________ City: _____________________________ State: __________ Zip Code: _________________ Program Director: ______________________________________________________________ Phone: ______________________________ Email: ___________________________________ ACTIVITY INVOLVEMENT: PROGRAM ACTIVITY Name of Committee or Activity: __________________________________________________ Position or Role: ___________________________________ Length involved: ____________
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