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Please enter your contact information below.(Required.)

First Name

Last Name

Preferred E-mail Address

Contact Phone Number

Suffix(Required.)

MD

DO

FAAFP

Additional/Other (please include other preferred suffix i.e. MPH, MBA, etc.)

Duty Station(Required.)

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

I am interested in the following:(Required.)

USAFP Board of Directors

USAFP Committee (https://usafp.org/committees/)

Attending AAFP National Conference of Constituency Leaders (https://www.aafp.org/events/aclf-nccl/nccl.html)

AAFP Commissions/Leadership (https://www.aafp.org/about/meet-our-leadership/commissions.html)

Other (please specify)

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.

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

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

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

Race/Ethnicity (optional):

Gender Identity (optional):

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

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

Uniformed Services Academy of Family Physicians Leadership Interest Form