2021-04-21 OMA Agenda - Board of Trustees

OMA Leadership Application Thank you for your interest in serving in a leadership role with the OMA Board of Trustees! Please type your responses. Attach additional pages as needed to provide complete answers to the following questions. Only include information and activity that has occurred within the last ten years. Your application MUST BE COMPLETELY filled out with as much DETAIL as possible to be considered. It is strongly recommended that all applicants have been a member for a minimum of three years, have attended a minimum of four OMA events, and have effectively served on at least one OMA committee. At the discretion of the OMA, some or all of the candidate information provided may be included publically on your candidate website.

First Name: __________________________ Middle Name/Initial: ______ Last Name: __________________________ Academic Designation & Professional Credentials (e.g., MD, DO, FAAFP, PA, NP, etc.): _______________________ For which position(s) are you interested in applying? □ Vice President (1-year term) □ Secretary/Treasurer (1 - year term) □ Trustee (2 - year term)

(Note: NP/PA applications are eligible for Trustee position only . This current term does NOT have any open NP/PA slots available. )

List your involvement with OMA committees: Committee name

Position Year(s) served on committee _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ List any other professional societies or associations in which you are or have been: a member or a board or committee member, and describe your level and length of involvement (e.g., committee chair, board member, general member, etc.). Note: active board or committee activities in acknowledged competitive professional societies or associations may be a disqualifying factor, if so determined by the Nominating Committee. Association name Level of involvement _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ List any other professional activities (e.g., publishing, non-OMA speaking engagements, faculty positions, etc.) Activity Dates of activity _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Application continues on next page.