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Certification of Allegations to AMSA Advocacy Board

INSTRUCTIONS: You must complete all the information on the form and initial to certify that the information is completely accurate in order for the Advocacy Board to consider your case. You can complete the information for yourself only. This information will be sent directly to the AMSA President, who will contact you within 2-3 working days of receiving the COMPLETED form. This form MUST be complete, and you must initial at the end to certify that all the information provided is accurate to the best of your knowledge. Please be assured that all information provided here is strictly confidential and be provided only to the AMSA President and members of the AMSA Advocacy Board unless you specify otherwise.

Student name:
(reporting for self only)
AMSA member number:
Email:
Phone:
Address:
City:
State:
Zip:
Institution:
Faculty members involved:
Allegations:
Student's perspective:

I certify that all information contained on this page is accurate to the best of my knowledge.
I give my permission to disclose my name and contact information to a student in a similar situation.
I give my permission to disclose my name, contact information, and perspective contained on this page to The New Physician magazine and other investigative newssource.

Please email attachments to: AMSA President, pres@amsa.org.
Mail to: AMSA National President, 1902 Association Drive, Reston VA 20191

   
   
 
 
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