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 2023 class. The application deadline is February 28, 2023. Questions? Contact Erica Hall, ehall@ncmedsoc.org, 919-833-3836.

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.*

First Name*

Last Name*

Degree <Select> MD DO PA-C *

Email Address*

Last 4-digits of Social Security #:*

Practice/Org Name*

Address:*

City, State Zip*

Are you a member of your county medical society

Yes

No

*

County Society Name*

Are you a member of your specialty society?

Yes

No

*

Specialty Society Name*

Please list any memberships in other state or national medical associations:*

Please list any memberships in civic organizations:*

Please list any leadership positions held in your practice setting and/or the community:*

Special interests/hobbies:*

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.)*

Question 1: Top 3 Issues*

*

2) What are three of your personal leadership goals? (1000 character limit)*

Question 2: Top 3 Goals*

*

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)*

Question 3: Benefits*

*

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?*

Committee Participation?

Yes

No

*

*

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.*

I agree.*