Vice Chairs Data Collection

Thank you for submitting your institution's vice chair information. Please complete one form per vice chair (multiple vice chair titles can be selected). The Alliance will record the information submitted for our records. If you have questions, please email memberservices@im.org.

First Name of Vice Chair *

Last Name of Vice Chair *

Vice Chair Email

Institution Name *

Please select all the Vice Chair titles this person holds for your institution *

Other Vice Chair Title(s)