Online Commission Nomination Form

Personal Information

  • Recommending Chapter:
  • Name:
  • Address:
  • Phone:
  • Fax:
  • Email:
  • Edit
  • Note: maximum image size is 4 MB. Recommended photo dimensions are 600 pixels in width by 600 pixels in height (standard passport dimensions).

Professional Profile

Review and complete the following information:

Education:

  • Medical School:
  • Residency:
  • State of Licensure:

AAFP and Chapter Membership

Nomination Profile

  • NOTE: It is expected that chairs selected will serve on a commission will be required to participate in additional activities, such as conference calls, webinars and other project work. The evaluation of commission member's contribution is part of the criteria for continuation on the commission.

  • The chair of the Commission on Continuing Professional Development (COCPD) and the COCPD Executive Committee (specifically, the chair and 4th year commission members) have no relevant conflicts per the AAFP's CME COI policy during their time on tenure.

  • Please check the category(ies) which apply to you in the box below, using the following definitions as a guide:*

  • People who self-identify as women.

  • People who reported their ethnicity and race as something other than non-Hispanic White as defined by the U.S. Census Bureau [i.e., African American, Asian, Native Hawaiian, or other Pacific Islanders, American Indian, Alaska Native, ethnic Hispanics, Other = not elsewhere defined.]

  • An active member who completed residency or extended training seven years ago or less.

  • A practicing physician is one actively engaged in providing patient care in a family medicine practice or other primary care health care setting.

    % time practicing

  • Physicians who participate in the education of professionals and/or in the pursuit of the discovery, integration, and/or application of medical knowledge.

  • Physicians involved in studies where new knowledge is gained to improve clinical care and/or practice improvement.


Select your top three AAFP Commission Preferences *

  • First Choice:

  • Second Choice:

  • Third Choice:


* Required field - must be filled out in order to submit form.