PHSAPA Board of Director Application

Public Health Service Academy of Physician Assistants Board of Directors Applicant Form
Rank or Professional Title
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
Employer
PA Program Attended
Year of Graduation
Are you an AAPA Member

YesNo
AAPA Member Number
Are you interested in applying for an Executive Board post or a Director post

Executive BoardDirectorBoth Executive Board & Director
Statement of Interest
Describe why you want to serve on the PHSAPA Board of Directors. What experience and skills do you have that that will advance the activities of the PHSAPA?
PHSAPA has 5 Executive Board positions. Self-nominations are accepted. Check the Director position of interest

PresidentPresident ElectVice PresidentSecretaryTreasurer
PHSAPA has 4 standing committees. Please check all that you would be interested in supporting

Membership & ElectionsContinuing Medical EducationWorkforce DevelopmentDiversity, Equity, & Inclusion
PHSAPA has 5 Workgroups. Please check all that you would be intrested in supporting

Name ChangeBylaws RevisionNew WebsiteCoin RedesignCommunications
Upload a copy of your CV

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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

Statement of Interest