Uniformed Services Academy of Family Physicians Leadership Interest Form

Thank you for your interest in serving the USAFP. Please submit this form and email a copy of your CV to mlwhite@vafp.org.

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Please enter your contact information below. (Required.)

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Suffix (Required.)

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Branch of Service (Required.)

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Duty Station (Required.)

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Current professional position (title, short description - not more than 50 words) (Required.)

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I am interested in the following: (Required.)

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Please indicate areas of skill, experience and/or interest in the first column and if you select an area in the first column, use columns 2-4 to indicate level of skill, experience, interest.

  I have a Skill, Experience, and/or Interest I have high expertise in this area/experience I have some expertise in this area/experience I have limited expertise in this area/experience but am interested in learning more
Continuing medical education
Finance, accounting
Graduate medical education
Information technology
Management
Outreach to future family physicians
Outreach to other organizations
Private sector advocacy
Public relations

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Why do you want to serve USAFP as a Board member, Liaison and/or Committee member? (not more than 125 words)

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Explain any unique skills, abilities, or perspectives you can bring to the organization. (not more than 125 words)

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Please list any groups or organizations that you could serve as a liaison to on behalf of USAFP. (not more than 125 words)

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Race/Ethnicity (optional):

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Gender Identity (optional):

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I identify as one or more of the following AAFP constituency groups. (optional)

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If there is any additional information you wish to share, please do so here. (not more than 125 words)

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