TMA Leadership College
Reference Form
INSTRUCTIONS
The TMA Leadership College
(TMALC) was established in 2010 as part of Texas Medical Association’s effort
to ensure strong and sustainable physician leadership within organized
medicine. TMALC graduates will be thought leaders who can close the divide among clinicians and health care
policymakers and serve as trusted leaders within their local
communities.
The applicant listed in
Section A of this document is submitting an application to participate in the
2017-18 program. Candidates are asked to provide two recommendations from physician
references who are familiar with past and/or potential leadership experiences. The
TMALC Executive Committee will utilize these references as part of the scholar
selection process.
On behalf of TMA and this
applicant, thank you for your time and investment in our future physician
leaders. Applications are due by June 1, 2017.
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SECTION A — CANDIDATE INFORMATION
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First
Name:
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M.I.:
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Designation:
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Preferred
Mailing Address:
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Apartment/Unit
No.:
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City:
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State:
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ZIP:
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Phone:
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E-mail:
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SECTION B — REFERENCE
INFORMATION
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Full
Name:
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Relationship:
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Company/Organization/Practice:
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Address:
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E-mail:
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City:
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State:
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ZIP:
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Phone:
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SECTION C – NOMINEE ASSESSMENT
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1. What three
leadership traits will this individual bring to the TMA Leadership College?
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2. In your experience, why
should this physician be selected to participate in the TMA Leadership College?
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3. Any Additional Comments?
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SECTION D — SUBMISSION
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Application submission deadline is June 1, 2017.
Thank you for
participating in the leadership selection process. Your input will be
invaluable. Please return this reference form to the TMALC applicant, or
forward directly to TMA via the following:
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+ MAIL
TMA Leadership College
401 W. 15th St.
Austin, TX 78701-1608
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8 E-MAIL
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6 FAX
TMA Leadership College
(512) 370-1693
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