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* 1. Provide your title

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* 2. Please select the position you are applying for:

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* 3. First Name

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* 4. Last Name

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* 5. Credentials

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* 6. Organization

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* 7. City, State

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* 8. Office Phone

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* 9. Cell Number

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* 10. Email Address

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* 11. Indicate primary board certification, date and other certification dates below:

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* 12. List positions held in the field of hospice and palliative medicine:

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* 13. List any positions of leadership within AAHPM (officer, committee chair, community chair, etc.):

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* 14. List any Hospice and Palliative Medicine non-published research (papers, posters or case studies) that you presented at either the Annual Assembly of Hospice and Palliative Care or another national conference. (e.g. ASCO, AAP, AGS, NHPCO, etc.) Please include a description of your role in the research or presentation:

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* 15. List authored research (systematic or narrative review) articles relevant to hospice and palliative medicine that you have published in a peer-reviewed journal (this may include the Journal of Pain and Symptom Management (JPSM)). Please include a description of your role in the research and in authorship of the publication:

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* 16. List any hospice and palliative medicine articles that you have published in a non-peer reviewed clinical publication (this may include blogs like Geri-Pal or Pallimed); include your role in authorship of the publication:

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* 17. List any service on an editorial board for a medical publication or as reviewer for any medical journal (this may include service on AAHPM Quarterly):

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* 18. Indicate your area(s) of expertise:

Select one or more options:

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* 19. Include a statement (200 words or less) that describes your interest in serving on the PC-FACS editorial team.

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* 20. Attach Curriculum Vitae (8 pages max)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 21. Attach writing sample

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 22. State role of authorship for the attached writing sample.

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* 23. I attest that the information I provided in this application accurately represents my professional status and experience. I understand that I must maintain my membership in AAHPM to remain on the PC-FACS editorial leadership team. Further, I recognize that any information on this application that is falsified may lead to the revocation on the editorial team of PC-FACS.

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