Appointments are made on the basis of knowledge, expertise, and interest.

Applying To:

Pediatrics Editorial Board

Position (specific position for which you are applying): Associate Editor of Case Reports
(See job description.)

* 1. Name

* 2. Specialty Area

* 3. AAP District

* 4. Office Address

* 5. Office Phone

* 6. Email

* 7. Home Address

* 8. Home Phone

* 9. Medical School and Year of Graduation

* 10. Year Elected as Fellow of AAP

* 11. Gender

* 12. AAP Membership Current

* 13. AAP Member ID

* 14. Present Position:
Please indicate the average number of hours/week spent in each of the 5 designated activities listed below:

* 15. How will your interests and expertise serve to complement the editorial/advisory board?

* 16. Describe your activities in AAP State Chapters or National Committees/Sections.

* 17. Are you a member of your AAP State Chapter?

* 18. Are you a current member on any other editorial board (including AAP publications) or the American Board of Pediatrics?

* 19. Community activities (ie, school board, health department, Head Start, health centers, community planning, regional medical programs, etc):

* 20. Please upload your CV in PDF or Doc/Docx format.

PDF, DOCX, DOC file types only.
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Please Note: You will receive an email containing a link to an electronic disclosure form. The disclosure must be completed and submitted to be considered for an editorial/advisory board position.

* 21. CERTIFICATION STATEMENT

I certify that the information provided in this application, in my CV, and in any other attachments hereto, is true and complete to the best of my knowledge. I understand that the AAP will rely on this information in making a decision regarding this editorial board appointment. The AAP treats all nomination materials as confidential. Applications, CVs, and other documents will be kept secure and will not be shared with anyone except designated AAP staff and the editorial leadership.

I understand that completion of this form in no way implies an appointment to this editorial/advisory board. I acknowledge that, if appointed, I must remain a member in good standing of the AAP. I further acknowledge that, if appointed, I will promptly and fully disclose any changes or potential new conflicts of interest that may affect my ability to impartially serve as a member of this editorial/advisory board. I understand that accepting this certification statement carries the same force as a signature.

Please check:

DEADLINE FOR RECEIPT OF NOMINATION MATERIALS IS 4:30 PM CST FRIDAY, DECEMBER 1, 2017
Questions to: Kate Larson at klarson@aap.org.

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