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* 1. Full Name

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* 3. Short Bio: Include your current role, your professional background, and any relevant career highlights that you feel represent your journey as a family physician and leader.

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* 4. Leadership Approach: Identify three leadership attributes that describe your style or philosophy. Select all that apply.

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* 5. Leadership Experience: Briefly outline any leadership roles you’ve held. Please highlight specific projects or initiatives where you’ve led a team or organization, particularly those that involved collaboration with administrative staff.

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* 6. Goals for the Program: What are you hoping to gain from this leadership program? Are there specific skills or insights you aim to develop to better engage with administrators on your ideas and projects?

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