The National Conference of Constituency Leaders (NCCL) provides an opportunity for members of Washington’s diverse constituencies to gather and meet with others from around the country to gain leadership skills and work on policy development for the American Academy of Family Physicians (AAFP).

The Washington Academy of Family Physicians (WAFP) has created an opportunity for five chapter delegates — one from each constituency — to attend the NCCL, build future leadership in the Washington chapter and foster special constituency participation at both the national and local levels. The Diverse Constituencies Subcommittee will review applications and select delegates to represent the WAFP.

Complete the following questions with as much detail as necessary. You may attach additional pages if necessary. Please do not substitute your CV for these questions.

To be considered for selection to represent the WAFP as a delegate to the National Conference of Constituency Leaders, candidate/delegate must be a member in good standing with the WAFP and AAFP and duly licensed to practice medicine in the State of Washington. All delegates to NCCL must attest to their eligibility. Appointment to the position is dependent upon verification of information. Checking the box below will serve as an attestation to your eligibility.

I attest that I am a member in good standing of the AAFP/WAFP; I am duly licensed to practice medicine in the State of Washington; and I am current with AAFP/WAFP/Local Chapter dues payment and AAFP CME requirements.

I further attest that I have no duality or conflict of interest to disclose that the Academy should be made aware of.

If I become aware of any potential challenges to my status as an AAFP/WAFP member in good standing, or any conflicts of interest, it is incumbent upon me to notify the WAFP president or EVP.