2021 PACEP Leadership Fellowship Application

PACEP Leadership Fellowship Application

Deadline for Application is January 7, 2022.
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Employer*
Phone Number*

Area CodePhone Number
Number of years as an ACEP/EMRA member*
Please list state/national emergency medicine activities in which you have participated (e.g. leadership positions; committee/task force involvement)*
Please list past or present leadership positions in organized medicine*
Please list memberships in other medical societies/associations*
Please describer your interest in the PACEP Leadership Fellowship, including why you should be selected by the Nominating Committee to participate. Include the knowledge, skills, abilities you bring to the Fellowship and how the Fellowship complements your personal and professional development and career goals. (max 500 words)*

0/500
Please describe how your participation in the Leadership Development Program might benefit PACEP, your physician group and/or hospital. (max 500 words)*

0/500
If selected, I agree to participate in all designated elements of the Leadership Development Program. I understand that absence from a required meeting, if not approved the the Fellowship Mentor and/or Board of Directors of PACEP, will result in dismissal from the program.
Please include your CV and any supplementary material(s) you would like the PACEP Nominating Committee to review concerning this application.*

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Please upload a letter of support from your Chief/Chair.*

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Signature*

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Date*
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