NH Physician Leadership Development Program Application

Thank you for your interest in the Physician Leadership Development program, a collaboration with the University of New Hampshire, the New Hampshire Medical Society, and the The New Hampshire Hospital Association.  Click here to download the brochure.

Important Dates:

• Applications now being accepted!
• Program Start Date:  TBD September 2024
• Graduation:  May 2026

Please fill out the application below electronically or  send your completed application packets can be emailed to:  PhysicianLeadershipNH@nhms.org or mailed to:
Physician Leadership Development Program
New Hampshire Medical Society
Two Capital Plaza, Ste 401
Concord, NH 03301

Materials Required for Selection Process 

• Completed application (click to download the application in MS Word or PDF format)  including:
• Resume/CV
• Letter of Support from your practice, hospital, or health system

Electronic Application:

Name *

First

Last

Nickname (if any)

Email *

Address *

Address Line 1

Address Line 2

City

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

Zip Code

Home Phone *

Cell Phone *

Your Current County of Residence *

Job Title *

Work Company Name *

Work Phone *

Work Address *

Address Line 1

Address Line 2

City

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

Zip Code

How did you hear about the New Hampshire Physician Leadership Program? *

If we are unable to select you for this year's cohort, are you willing to consider participation next year, beginning in September 2025? *

• Yes
• No

Resume or Curriculum Vitae (CV) *

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

Please include your resume or CV including your employment and educational history.

Essays: 1. What do you hope to accomplish personally through this program? *

2. How do you hope to change or influence you practice or organization? *

Upload a Letter of Support from your practice, hospital or health system *

Click or drag files to this area to upload. You can upload up to 3 files.

Organizational Commitment: I have spoken to my practice/hospital/health system regarding the NH Physician Leadership Development program materials. Please include a letter of support attestation from your practice, hospital or health system for both your eligibility as a program candidate, as well as the organization’s support of the time commitment involved to participate in the entire two-year curriculum. * I understand the expectations and am fully able to participate in New Hampshire Physician Leadership Development Program. For consideration, this box MUST be checked *

• Yes

Submit