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Public Health Service Academy of Physician Assistants Board of Directors Applicant Form
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Name

Last NameFirst Name
Personal Email
example@example.com
Work Email
example@example.com
Personal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Phone
Work Phone
Agency
Are you an AAPA Member

YesNo
AAPA Member Number
Statement of Interest
Describe why you want to serve on the PHSAPA. What experience and skills do you have that that will advance the activities of the PHSAPA?
PHSAPA has 4 standing committees. Please check all that you would be interested in joining.

Membership & ElectionsContinuing Medical EducationWorkforce DevelopmentDiversity, Equity, & Inclusion
PHSAPA has 4 Workgroups. Please check all that you would be intrested in joining.

Bylaws RevisionCoin RedesignNew WebsiteName Change
I certify, by my signature, that the information contained within this application and all supporting documents (i.e., resume, recommendation letters, etc.) is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.
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Public Health Service Academy of Physician Assistants Board of Directors Applicant Form