2017NCCL Delegate Application

The National Conference of Constituency Leaders (NCCL) provides an opportunity for members of Washington’s diverse constituencies to gather and meet with others from around the country to gain leadership skills and work on policy development for the American Academy of Family Physicians (AAFP).

The Washington Academy of Family Physicians (WAFP) has created an opportunity for five chapter delegates – one from each constituency – to attend the NCCL, to build future leadership in the Washington chapter and foster special constituency participation at both the national and local levels. The Diverse Constituencies Committee will review applications and select delegates to represent the WAFP.

CRITERIA FOR SELECTION

General:

1. Membership in the WashingtonAcademy of Family Physicians.

2. Previous or current service in the WAFP.

3. Any other appropriate information to aid the Committee in evaluation.

Constituencies Represented by Delegates:

Gay, Lesbian, Bisexual and Transgender Physicians—an active memberof AAFP who self-identifies as GLBT or who is supportive of GLBT issues.

International Medical Graduate (IMG) Physicians—an active member of AAFPwho graduated from medical school outside the United States, Canada or Puerto Rico.

Minority Family Physicians—an active member of AAFPwho isAmerican Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander; by ethnicity as Hispanic or Latino.

New Physicians—an active member of AAFPwho has been in practice less than seven years.

Women Physicians—an active member of AAFPwho is a woman.

All nominations and supporting materials must be submitted by

February 10, 2017. Entries submitted after the deadline will not be considered.

Please return application form and supporting materials to:

WashingtonAcademy of Family Physicians

1239 - 120th Avenue NE, Suite G

Bellevue, WA 98005

Fax: 425-747-3109

NCCL DELEGATE APPLICATION

Full Name: ______AAFP ID Number: ______

Address______

City______State ______Zip ______

Email ______Phone ______

NCCL Delegate Position interested in:

Women Minority GLBT IMGs New Physician

Complete the following questions with as much detail as necessary. You may attach additional pages if necessary. Please do not substitute your CV for these questions.

1) Current profession position or practice circumstance:

2) Positions held in the AAFP/WAFP(none required):

3) Other medical society affiliations:

4) Please describe your interest in attending the National Conference of Constituency Leaders:

To be considered for selection to represent the WAFP as a delegate to the National Conference of Constituency Leaders, candidate/delegate must be a member in good standing with the WAFP and AAFP, and duly licensed to practice medicine in the State of Washington. All delegates to NCCL must sign a statement attesting to their eligibility. Appointment to the position is dependent upon verification of information.Please sign the statement below.

I attest that I am a member in good standing of the AAFP/WAFP; I am duly licensed to practice medicine in the State of Washington; and I am current with AAFP/WAFP/Local Chapter dues payment and AAFP CME requirements.

I further attest that I have no duality or conflict of interest to disclose that the Academy should be made aware of.

If I become aware of any potential challenges to my status as an AAFP/WAFP member in good standing, or any conflicts of interest, it is incumbent upon me to notify the WAFP President or EVP.

Name:Signature:

Date: