Family Medicine Leadership Experience Application
Full name *
Your answer
Email *
Your answer
Are you still in training in a residency or fellowship?
If yes, please specify your year in training and the program. Note: we may limit the number of residents and fellows accepted into the program.
Your answer
Please list up to four medical-related leadership positions you currently hold or have previously held. Provide organization name, position, and dates.
Your answer
Please list up to four other organizations of which you currently are or have previously been a member or leader.
Your answer
Why are you interested in TAFP’s FMLE and why should you be chosen as a participant? *
Your answer
If selected, I agree to participate in all required educational and networking sessions of TAFP’s Family Medicine Leadership Experience as specified in the program outline. I agree that TAFP can use my photograph and name to promote future leadership programs. *
Required
Applications are due Saturday, December 15, 2019.
In addition to your completed application please submit a copy of your CV. Submit your application by mail, email, or fax.
Mail: Texas Academy of Family Physicians
12012 Technology Blvd. Suite 200
Austin, TX 78727
Email: kmccarthy@tafp.org
Fax: (512) 329-8237
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