MDAFP-F Board of Directors Application

Name Name First Last
Credentials

MD, DO, FAAFP, etc.
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Review the MDAFP Conflict of Interest Disclosure Policy

Click Here to Read the Policy
I do not have a conflict of interest, as described above. I do not have a conflict of interest. However, in the spirit of full disclosure and in the event that such information would be deemed relevant by others, I have listed my activities/interests/affiliations below. I do have a potential conflict(s) of interest and I have listed such conflicts(s) below.
Please list any activities that you wish to disclose that may constitute a conflict of interest. Provide all relevant information including:

1) The nature of those activities which you are listing
2) The types of financial arrangements (if any) between you and any third parties involved in those activities
3) A description of the business or purpose of such third parties
List Activities/Interests/Affiliations below:
Please select the position(s) you are interested in applying for:

Please select the position(s) you are interested in applying for: Foundation Director
Upload a 2-page summary CV. If more than 2 pages are uploaded, only the first 2 pages will be shared with the Nominating Committee

Attach Files
Describe your past involvement in MDAFP (if applicable)
Describe your past involvement in AAFP (if applicable)
Statement of Interest in serving on the Board
What perspectives and skill set would you bring to the Board?

MDAFP-F Board of Directors Application

MDAFP-F Board of Directors Application

Review the MDAFP Conflict of Interest Disclosure Policy

Please list any activities that you wish to disclose that may constitute a conflict of interest. Provide all relevant information including: