National Physicians Alliance

Leadership Application Form

First Name*

Last Name*

Email*

Phone*

Cell Phone

Work Phone

Street*

Street 2

City*

State/Province*

Zip/Postal Code*

Specialty

Gender

Year of Birth

Please list, in descending order, your top six preferred NPA positions.

Would you be willing to serve in more than one position (e.g., A board positions and committee position, or multiple committees)?

Would you be willing to serve in any position available, even one that you did not list above? (Note: every effort will be made to appoint applicants to their first choice of position.)

AFTER SUBMITTING THIS FORM, please send both your C.V. and a statement of purpose to candidates@npalliance.org. If you prefer to mail hard copies of these documents, our address is 1902 Association Drive, Reston, Virginia, 20191. Your statement of purpose should include a brief description of your current medical practice/position, your leadership experience, and any special skills you would bring to the NPA. We look forward to reviewing your application. Please note that the NPA reserves the right not to fill every available position.