Nomination Form
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SECTION A - NOMINEE PROFILE (to be completed by the Nominee or Nominating Organization)
First Name *
Last Name *
Preferred Mailing Address *
Home
Office
Address 1 *
Address 2
City *
State *
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WI
WY
Zip *
Phone *
Alt. Phone (cell) *
Fax *
E-mail *
Number of years an NCMS member
Number of years a county society member
Currently a member of which county society?
Number of years a specialty society member
Specialty
Currently a member of which specialty society?
Please list county, specialty, and/or NCMS activities in which the nominee has participated (i.e. committee member, section member, etc.) and/or held a leadership position (i.e. committee chair, AMA delegate, county officer, etc.)
Please list the nominee's membership in other medical associations.
Please list any medically related leadership positions held in the community.
Hobbies / Special Interests
SECTION B - NOMINEE Assesment (to be completed by the Nominee)
Please describe your interest in the Leadership College, including why you should be chosen by the Selection Committee to participate.
(please limit to 250 words)
Please describe how your participation in the NCMS Leadership College will benefit your county and/or specialty society or the NCMS.
(please limit to 250 words)
In addition to participating in your county or specialty society, are you interested in participating in North Carolina Medical Society committees, task forces, projects or leadership positions?
Yes
No
Please describe your areas of interest and/or expertise.
Name of nominating organization (i.e., county medical society, specialty society, or NCMS) *
Contact at Nominating Organization
First Name
Last Name
Phone
E-mail
Please upload a photo for use on publications/LC website.
Upload your current CV for our records.
