TMA Leadership College
Application
INSTRUCTIONS
Please complete this application in its entirety. The
TMA Leadership College Executive Committee will review only those applications with
every required field addressed. Therefore, please do not only write “see
attached CV.”
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SECTION A — NOMINEE
PROFILE
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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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County
Medical Society:
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Specialty
Society (if applicable):
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Please list up
to four county, specialty, and/or TMA activities (e.g., committee member,
section member), or leadership positions (e.g., committee chair, AMA delegate,
CMS officer) in which you currently participate or have previously participated.
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Activities/Leadership
Positions
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From:
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To:
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From:
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To:
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From:
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To:
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From:
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To:
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Please list up to four medical-related
leadership positions you currently hold or have previously held (e.g., chief of
staff, Red Cross chair, blood drive committee member).
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Leadership Positions
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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Please list up
to four other organizations of which you are or have been a member (e.g.,
Chamber of Commerce, Rotary Club).
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Organization
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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City:
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State:
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From:
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To:
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SECTION B – NOMINEE ASSESSMENT
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Please
answer the following questions that will help the committee know you better.
Why are you interested in
the TMALC and why should you be chosen to participate?
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List your primary
interests/passions regarding health care issues.
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SECTION C — REFERENCES
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Please list two
physician references. Include valid email and phone number for
each reference.
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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
(required):
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City:
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State:
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ZIP:
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Phone: (required):
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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
(required):
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City:
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State:
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ZIP:
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Phone: (required):
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SECTION D — APPLICATION
SUPPORT DOCUMENTS
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Please
check the boxes to indicate you have included the following items as part of
your application:
Recent professional photograph
(headshot) to be used in TMALC publications and website (jpg preferable)
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SECTION E — AGREEMENT AND
SIGNATURE
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If
selected, I agree to participate in all required educational and networking
sessions of the TMA Leadership College as specified in the program outline. I
agree that TMA can use my photograph and name to promote future leadership
programs.
Signature of Nominee: Date:
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SECTION F — SCHOLARSHIP
ASSISTANCE
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A limited
number of scholarships are available to support scholar travel expenses.
Priority will be given to scholars traveling outside metropolitan areas or to
those demonstrating financial need. Indicate below if you wish to apply for a scholarship and a
separate scholarship form will be sent to you.
Yes, I would like to apply for scholarship
funds
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SECTION G — SUBMISSION
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Application submission deadline is June 1, 2017.
In addition, to your application, please
submit two physician recommendations. These references should be familiar with
your leadership experience. Reference
forms may be accessed at www.texmed.org/leadership.
Submit your application in one of three
ways:
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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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