Committee Application

Committee Application Form

Please complete and submit this application form if you are interested in applying to serve on a SEMPA Committee. You are also required to submit several documents as part of your application. Since all the documents need to be submitted at the same time, make sure to have everything completed and ready to email 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.

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Date *

Name *

First

Last

SEMPA Member Number *

If you don't know, please email sempa@sempa.org or call 877.297.7594

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone

NCCPA Certificate # *

Please indicate which Commitee(s) you are applying for: *

• Advocacy Committee
• Education Committee
• EMS Committee
• Post Graduate Committee
• Rural Health Committee
• Wellness Committee

If you have served on a SEMPA Committee before, please indicate the Committee and the year(s) served you served on the Committee: *

Please list any other Board of Director or Committee positions you currently hold with any other organization: *

I have read, understand, signed and agree to uphold the SEMPA Leadership Agreement and Leadership Conflict of Interest Policy and Disclosure Forms. *

• Yes
• No

Include the following documents with your submission.

 

Current CV *

Click or drag a file to this area to upload.

Signed SEMPA Leadership Agreement *

Click or drag a file to this area to upload.

• Signed Conflict of Interest Policy and Disclosure *

Click or drag a file to this area to upload.

Letters of support (not necessary but welcomed)

Click or drag files to this area to upload. You can upload up to 5 files.

Submit