HCLM

Step 3: Apply to become part of HCLM

Download the PDF version here or complete this form online (Note: due to some compatibility issues with Internet Explorer, the online form works best in Google Chrome).

We are currently accepting applications for the 2019 class. The application deadline August 31, 2018. Questions? Contact Kristina Natt och Dag, tnattochdag@ncmedsoc.org, 919.833.3836 ext. 158.

Please complete the following:

Section 1
The NCMS Foundation Board of Trustees, or a subcommittee thereof, will review this nomination, which must be completed in its entirety. PLEASE NOTE: You will not be able to partially complete the form and save your responses for later; it is suggested that you review the form and then copy and paste your longer responses from another source such as Word or Notepad.
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Section 2
NOTE: For best results, copy your pre-written text (preferably from Notepad or other simple text editor) and paste into the text areas below.
1) Please briefly describe the top three issues physicians/PAs face today and the opportunities for leadership. (Please limit to 1000 characters or less.)
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2) What are three of your personal leadership goals? (1000 character limit)
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3) Please describe how your participation in HCLM will benefit you and your practice setting; county and/or specialty society; or the NCMS. (1000 character limit)
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The purpose of the Kanof Institute for Physician Leadership is to also assist you in gaining skills to serve a leadership role locally, regionally or statewide. Are you interested in participating in NCMS committees, task forces, projects or leadership positions?
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Section 3
If selected, I agree to complete a project of my choice and to fully participate in all required educational and networking sessions of HCLM as specified in the Program Guidelines.
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The North Carolina Medical Society

Physical Address:
222 N. Person Street
Raleigh, NC 27601
Get Directions
Phone:
919.833.3836
800.722.1350 (NC only)
919.833.2023 FAX
Mailing Address:
PO Box 27167
Raleigh, NC 27611
 
 

 

Medical Mutual

The NCMS is a proud partner with
Medical Mutual.