Committee 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 Yes No

What committee(s) are you applying for? Advocacy Committee Education Committee EMS Committee Postgraduate Education Committee

Have you served on a SEMPA committee before? Yes No

If yes, what committee(s) and what year(s)?

Do you currently serve on any other boards or committees for any other organization? Yes No

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. Yes No

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.

File upload

Application Checklist

I have uploaded the following documentation to my application. Current CV One-page statement explaining why you are interested in serving on the committee(s) and what you will bring to the committee(s) Signed SEMPA Leadership Agreement Signed Conflict of Interest Policy and Disclosure Letters of support (not necessary but are welcome)