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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).
 
Applicant:
First Name Middle Name Last Name Suffix Title(s)
 
I am nominating myself for a leadership position with PAFP:
select
 
Recommended By:
First Name Middle Name Last Name Suffix Title(s)
 
Practice Type:
select
 
   
 
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.)
INVOLOVEMENTS OR ACHIEVEMENTS IN THIS AREA
(i.e. board/committee appointments, advocacy, CME, etc.)
INTEREST LEVEL
Board Governance
select
Education
select
Finance
select
Legal & Governmental Affairs
select
Member Services
select
Practice Advocacy
select
Resident & Student Affairs
select
 
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 INVOLOVEMENTS OR ACHIEVEMENTS IN THIS AREA INTEREST LEVEL
Community Outreach
select
Information Technology
select
Marketing / Public Relations / Communications
select
Practice Management
select
Other area you feel is important and you have experience
select
 
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:
 
 
 

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