Leadership Identification Program Questionnaire

LEADERSHIP IDENTIFICATION PROGRAM QUESTIONNAIRE - FORM LIP

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

E-mail:

AAPA ID #:

Are you interested in volunteering at the national level?

No

Yes

Tell us about your strengths and skills (e.g. detail-oriented, writing, editing, public speaking, accounting, etc.).

Are you currently volunteering for a constituent organization? If yes, which one(s)?

No

Yes

Tell us about your interests (e.g. CME planning, governance, PA practice issues, Congressional Visits Program, etc.).

If you are interested in volunteering with a constituent organization, consider participating in the Constituent Organization Leader Recruitment (COLOR) program. Fill out this application (http://www.formsite.com/aapa2/form994105303/index.html) and AAPA staff will help you make your first connection with the constituent organization of your choice. If you have questions about the program please contact Kodi Blue Erb, 703/836-2272, ext 3127, kerb@aapa.org.

* Indicates Response Required