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.

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* Suffix

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* Branch of Service

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* Present Duty Station and Assignment

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* Medical School, Year Graduated

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* I am interested in the following:

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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)

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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)

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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)

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* Race/Ethnicity (optional):

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* Gender Identity (optional):

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

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