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SEMPA Committees

Application Form

Please complete and submit this online application form if you are interested in applying to serve on a SEMPA Committee.

You will be required to submit several documents as part of your application. Since all the documents need to be submitted at the same time you submit your completed application, make sure to have everything completed and ready to upload as a PDF document before you begin filling out the application. There are instructions below on how to upload all the documents at once into our document portal.

If you have any questions or problems with the application, email us at sempa@sempa.org or call 877.297.7594. 

Name
SEMPA Member Number (if you need this, email membership@sempa.org or call 877-297-7594)
Address
Email
Cell Number
Home Number
NCCPA Certificate #
Certificate of Added Qualifications (CAQ) in Emergency Medicine
What committee(s) are you applying for?
Have you served on a SEMPA committee before?
If yes, what committee(s) and what year(s)?
Do you currently serve on any other boards or committees for any other organization?
If yes, please list your position and organization.
I have read, understand, signed and agree to uphold the SEMPA Leadership Agreement and Leadership Conflict of Interest Policy and Disclosure Form.

Uploading to Document Portal
To upload the required documents, click the "Choose Files" button below. Hold down the CTRL (Windows) or CMD (Mac) button on your keyboard and click on the files you want upload. When all the files you want to upload are highlighted, hit "Open". All the files will upload at once.

If you try to upload your files separately, the system will override the previous file uploaded so you won't be able to submit all the required documents. 

Application Checklist

I have uploaded the following documentation to my application.