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Uniformed Services Academy of Family Physicians Leadership Interest Form
Thank you for your interest in serving the USAFP. Upon completion of this information, your responses will be forwarded to USAFP Leadership.
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Please enter your contact information below.
(Required.)
First Name
Last Name
Preferred E-mail Address
Cell Number
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Suffix
(Required.)
MD
DO
FAAFP
Additional/Other (please include other preferred suffix i.e. MPH, MBA, etc.)
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Branch of Service
(Required.)
Air Force
Army
Coast Guard
Guard
Navy
Public Health Service
Reserve
Space Force
Civilian
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Present Duty Station and Assignment
(Required.)
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Medical School, Year Graduated
(Required.)
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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.htm
l)
AAFP Commissions/Leadership (
https://www.aafp.org/about/meet-our-leadership/commissions.html
)
Other (please specify)
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Past Participation in the USAFP i.e. years of membership, positions held, attendance at annual meetings, etc. (please submit in list form not more than 300 characters or 50-60 words)
(Required.)
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Other qualifications for leadership i.e. present or past experiences and/or responsibilities contributing to qualifications for the position you are interested in being nominated for. (please submit in paragraph form not more than 300 characters or 50-60 words)
(Required.)
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Personal Statement on why you want to hold this position. (please submit in paragraph form not more than 300 characters or 50-60 words)
(Required.)
Race/Ethnicity (optional):
Gender Identity (optional):
I identify as one or more of the following AAFP constituency groups. (optional)
International Medical Graduate
LGBTQ+ Physician or Physician Ally
New Physician (in practice less than 7 years)
BIPOC (Black, Indigenous, Person of Color)
Woman
