APM Institutional Affiliate Member Nomination Form

Review APM affiliate membership criteria

_____________________________________________________________________________________

Please use proper capitalization when completing the form. Fields marked with an asterisk must be completed.

Nominator Information (Chair of Medicine)

First Name *

Middle Initial

Last Name *

Suffix 1 *

Institution *

Phone *

Email Address *

Nominee Information

First Name *

Middle Initial

Last Name *

Suffix 1 *

Title

Subspecialty (if applicable)

Phone *

Email Address *

Is the nominee at the same institution as the nominator? *

Yes

No

If No, please complete the following information.

Institution

Address 1

Address 2

City

State/Province

ZIP Code

Nominee at different institution

I attest that the nominee’s institution listed above has a formal affiliation with the medical school where I currently serve as chair of the department of internal medicine. I understand that if approved, the nominee's APM membership will belong to the affiliated medical school.

*

Acknowledge and Affirm

Faculty Appointments

1) Institution *

Title *

Academic Rank *

If other, please state their academic rank.

2) Institution

Title

Academic Rank 2

If other, please state their academic rank.

Curriculum Vitae

Please attach the nominee's curriculum vitae.

To attach a file, select Browse, then navigate to the file you would like to attach. Select the file and click Open. The path to your selected file will appear next to the Browse button.

Nominee's curriculum vitae *

Affirmation

By checking the box below and submitting this form, as chair of the department of medicine and current APM institutional member, I do hereby acknowledge and affirm that the individual being nominated holds a faculty appointment at the LCME or CACMS accredited medical school where I currently serve as chair. The nominee has exhibited leadership in the department of internal medicine in areas related to research, education, or clinical care which is documented in the attached curriculum vitae. *

Acknowledge and Affirm