PAFP/F: PAFP Leadership Application Form

PAFP Leadership Application Form

Thank you for expressing interest in serving in a leadership position with the Pennsylvania Academy of Family Physicians (PAFP). Applications are evaluated based on current and past participation in PAFP activities, as well as on specific qualifications and core competencies necessary for effective leadership and governance of the organization. The PAFP Governance and Leadership Committee selects a slate of recommendations to present to the Board of Directors and eventually to the membership 45 days in advance of the PAFP Annual Business Meeting, where final approval is determined.

Please complete this form and then send a Letter of Interest and curriculum vitae to assist in deliberations for selecting the most qualified candidates, and send to: John S. Jordan, CAE, Executive Vice President and CEO (jjordan@pafp.com).

RESIDENTS: Please note for PGY 1 & 2 residents, if you are applying for a Committee position please apply thru the Residency Assembly which meets in April. If you have any questions please contact Molly Talley at mtalley@pafp.com.

After completing your Leadership Application please submit your curriculum vitae to John Jordan at jjordan@pafp.com. Lastly, please remember to complete your conflict of interest statement.

Applicant:

First Name	Middle Name	Last Name	Suffix	Title(s)

I am nominating myself for a leadership position with PAFP:

Recommended By:

First Name	Middle Name	Last Name	Suffix	Title(s)

Practice Type:

PAFP OFFICERS/BOARD DIRECTOR Please rank your top three, 1st - 3rd, positions based upon your qualifications Click here to view position descriptions

President-Elect
Board Director-At-Large
Foundation President
AAFP Delegate
AAFP Alternatve Delegate

PAFP COMMITTEES Please rank, 1st - 4th, your preference Click here to view committee descriptions

Governance & Leadership Development Committee
Resident & Student Affairs Committee
Continuing Professional Development Committee
Governmental & Practice Advocacy Committee

CORE COMPETENCIES, INVOLVEMENTS AND INTERESTS Below are the primary areas in which the PAFP focuses effort in order to best serve members - as a result, the PAFP seeks in leaders a combination of experience and interest that will advance our efforts most effectively:

COMPETENCY AREA	RELATED SKILLS (i.e. leadership positions, advocacy efforts, accounting, etc.)	INVOLVEMENTS OR ACHIEVEMENTS IN THIS AREA (i.e. board/committee appointments, advocacy, CME, etc.)	INTEREST LEVEL
Governance & Leadership Committee
Continuing Professional Development Committee
Resident & Student Affairs Committee
Governmental & Practice Advocacy Committee

ADDITIONAL COMPETENCIES, INVOLVEMENTS AND INTERESTS Experience in the following areas is also considered valuable in the PAFP's ongoing efforts to serve its members. Please indicate your skills/involvements/interest (if any) in:

COMPETENCY AREA	RELATED SKILLS	INVOLVEMENTS OR ACHIEVEMENTS IN THIS AREA	INTEREST LEVEL
Community Outreach
Information Technology
Marketing / Public Relations / Communications
Practice Management
Other area you feel is important and you have experience

Please list past or current leadership positions with other medical associations or health care entities (AAFP, hospitals, etc.) and community organizations:

Please explain briefly why you want to serve in a leadership role with the PAFP:

What else would be helpful for the PAFP to know about you?:

Please list two (2) professional references who would be willing to be contacted by PAFP leadership for additional information about you:

Name:
Nature of Relationship:
Phone No.:
Email:

Name:
Nature of Relationship:
Phone No.:
Email: