Az Psych 2021 Executive Officer and Committee Interest Submission Form

Az Psych 2021 Executive Officer and Committee Interest Submission Form
Thank you for your interest in contributing to the leadership of the Arizona Psychiatric Society. Please complete the information below and submit the same by the deadline of February 1, 2021.
Name *

First Name Last Name
Email *
example@example.com
Preferred Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *

Area Code Phone Number
Work Organization or Residency/Fellowship Program *
Nature of Work Affiliation *

Hospital Public / AHCCCS Provider VA Treatment Facility Private Practice Medical School
Psychiatric Practice Type *

General Adult Child & Adolescent Geriatric Addiction Forensic Consultation Research Administration/Managed Care Training/Teaching
Arizona Psychiatric Society Leadership Service. *
Please list any committees, caucuses, positions, fellowships, or work groups that you have participated in previously or are currently a part of in APS and the approximate timeline of the same:
Leadership Service in the APA or Other Physician or Health Care Organizations. *
Please list any other county, state, or national psychiatric or physician professional associations in which you are a member, and also please list where you are serving in any leadership capacity or contributing to a committee or work force of the same. If none, please state none.
Please select which executive officer position you are applying for (or if only submitting to express an interest in a Committee, please select None for this question). For more information on any of these positions, please contact teri@azmed.org: *
Nominee's Vision and Leadership Statement *

Please provide your vision for the future of the Society and how you feel you can or will contribute to the same. Word count is limited. 0/300
Please select which Committee or Work Group you would like to be added to (provided your membership is current, we will add you to these groups upon receipt of this form) (if only submitting this form for interest in executive office, please select None for this question). For more information on any of these positions, please contact teri@azmed.org. *
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