MAFP Board of Directors Commitment & Nomination Form Michigan Academy of Family Physicians is seeking members for the Academy’s Board of Directors and Officers. MAFP values diverse leadership as the Board is strengthened by differences among members in race, gender, ethnicity, age, sexual orientation, religion, practice areas and settings (solo, group practice, employed, academic, urban, rural, etc.), geographical regions, and philosophies about the Family Medicine specialty. Board members serve in an advisory capacity on behalf of the Academy. Board Member requirements and responsibilities are listed below: Be a member in good standing of MAFP. Support the mission of MAFP, which is to support Family Physicians in Michigan through leadership, collaboration, and innovations to achieve the best patient outcomes. Be willing to commit the necessary time to serve on the Board of Directors (attend quarterly meetings), and to serve on one or more MAFP committee. When possible, represent MAFP and its members at various events and programs. Develop an understanding of MAFP’s governing process and the issues impacting Family Medicine and Family Physicians. (Please note that an orientation is required of all new Board members.) Attend the Michigan Family Medicine Annual Conference & Expo and Annual Meeting of Members (held in the summer) to provide input on deliberations involving Academy governance. To be considered to serve on the MAFP Board of Directors, submit this completed form and an up-to-date copy of your curriculum vitae no later than March 1. To submit your CV, email it to info@mafp.com; fax it to 517.347.1289; or mail it to MAFP, Attn: Board of Directors Nomination, 2164 Commons Parkway, Okemos, MI 48864.By submitting this commitment and nomination form, you are attesting that, if selected, you can fulfill the requirements and responsibilities listed above. Question Title * 1. This nomination is a: Self-nomination Nomination by a colleague* *If this is a nomination by a colleague, does the nominee know that he/she has been nominated? Question Title * 2. Nominee's Contact Information First/Last Name, Designation/Certification Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Email Address Best Number to Call Question Title * 3. Nominator's Contact Information (if this is a nomination by a colleague) First/Last Name, Designation/Certification Address City State ZIP Email Address Best Phone Number to Call Question Title * 4. Please consider this nomination for the following position(s) (check all that apply): Member-at-Large Director President-elect Vice President Speaker Chapter Delegate to the AAFP Congress of Delegates Chapter Alternate Delegate to the AAFP Congress of Delegates Resident Chair Student Chair Question Title * 5. What is your/the nominee's primary practice type? Academic Administration Emergency Medicine Family Medicine Group Military Multi-specialty Group Research Solo Urgent Care Resident Student Other (please specify) Question Title * 6. What is your/the nominee's secondary practice type (if applicable)? Academic Administration Emergency Medicine Family Medicine Group Military Multi-specialty Group Research Solo Urgent Care Resident Student Other (please specify) Question Title * 7. Where is your/the nominee's practice located? Rural Urban Inner city Hospital Clinic Office Other (please specify) Question Title * 8. Are you/the nominee an International Medical Graduate? Yes No Question Title * 9. Have you/the nominee served on the MAFP Board of Directors in the past? Yes No If yes, what year(s)? Question Title * 10. Have you/the nominee served on an MAFP Committee in the past? Yes No If yes, what committee(s) and what year(s)? Question Title * 11. List other medical societies in which you/the nominee are a member and/or participate: Question Title * 12. Why are you/the nominee interested in serving on the MAFP Board of Directors? Question Title * 13. What qualities, skills and/or expertise would you/the nominee bring to the Board? Question Title * 14. What arrangements have you/the nominee made in your practice, teaching or administrative position to permit you/the nominee to actively participate in MAFP meetings held quarterly (approximately 3-4 hours plus travel time), and on one or more MAFP committee (committees meet 2-4 times annually)? Question Title * 15. There may be a time when you/the nominee will be needed to represent an Academy position that you/the nominee personally oppose. Should such an occasion arise, how would you/the nominee handle this? Question Title * 16. Do you believe you/the nominee have a grasp of the issues and concerns facing MAFP and/or the specialty of Family Medicine? How do you/the nominee stay informed? Question Title * 17. On a scale of 1 to 10, what is your/the nominee's comfort level if asked to respond to issues from the media and/or legislators? Question Title * 18. Is there any additional information or other comments you would like to share with the Nominating Committee for its consideration? After completing this form, submit an up-to-date copy of your curriculum vitae no later than March 1, in one of three ways:Email: info@mafp.com Mail: Michigan Academy of Family Physicians, Attn: Board of Directors Nomination, 2164 Commons Parkway, Okemos MI 48864 Fax: 517.347.1289 Done