To be completed by the Physician Applicant
Instructions: Please complete each entry on this form. Once completed, click "submit" at the bottom of the page to enter your application for consideration to participate in the Medical Society of Virginia Foundation's 2010-11 Claude Moore Physician Leadership Institute. Submission of an application does not guarantee acceptance to the program. Applications will be reviewed by an external committee, and decisions will be made and communicated to applicants by June 30, 2010.

Questions? Please contact Katy Sawyer, MSVF's Institute Director, at 804 | 377-1004 or click here.

All questions and fields below require a response.

1.)  Are you a licensed physician working in Virginia? Yes     No If not, the Claude Moore Physician Leadership Institute is not able to consider your application.
2.)  Are you currently a member in good standing of the Medical Society of Virginia? Yes     No Membership is required for participation in the Institute. For MSV membership information, please contact Kathleen Bozis, Membership Coordinator, at 804 | 377-1042 or 800 | 746-6768, ext. 1042, or click here. 3.)  Please provide the following information:
Name:	,
Primary Work Organization Name:
Primary Work Mailing Address:
Work Phone:
Home Address:
Home Phone:
Cell Phone:
E-mail:
Specialty/Practice Type:
4.)  Please list your current membership(s) in other national/local/specialty societies and/or medical associations.
5.)  Please list your current medically-related leadership positions held in the community.
6.)  Please describe your interest in the Claude Moore Physician Leadership Institute, including why you would like to participate. (Please limit your response to 500 words or less.)
7.)  Please describe how your participation in the Claude Moore Physician Leadership Institute could benefit your patients, practice, community, the Commonwealth of Virginia, and/or beyond. (Please limit your response to 500 words or less.)
MSVF is seeking participants who are committed to learning and self-motivated to do the work, are ready to expand beyond their practice focus, and want to embrace the challenge of thinking "outside the box" to seek improvements in Virginia's health care system. Please check each to signify your willingness to comply with the following program expectations:
Participant must commit to attend all required meetings and activities of the Claude Moore Physician Leadership Institute (see 2010-11 Institute Schedule).
Participant will submit a one-time tuition fee of $1,000 to MSVF upon acceptance to the program.
Participant is responsible for Institute-associated travel and lodging costs.
Participant agrees to identify and attend a specialized leadership training seminar during the course of the year (for some suggested options, please refer to the 2010-11 Specialized Leadership Training Options).
Participant agrees to purchase all required Institute texts (estimated cost $150 total).
Participant agrees to cooperate with all Institute reporting requirements.
Participant agrees to participate in future Institute Alumni Program activities as appropriate.
Participants should be proficient in using e-mail and the internet to communicate with MSVF staff, faculty and peers.