AGPJ AWARDS — MEMBER PROFESSIONAL UPDATE FORM

AGPJ AWARDS — MEMBER PROFESSIONAL UPDATE FORM

(Physician completes for self-record update)

AGPJ Awards Professional Profile Update

Purpose:

This form allows AGPJ members to record achievements supporting consideration for AGPJ

internal awards.

SECTION 1 — MEMBER DETAILS

Full Name

First name

Last name

Practice Name

Email Address

Telephone Number

MCJ Registration Number

Years in Practice

SECTION 2 — AGPJ INVOLVEMENT

Describe your involvement with AGPJ:

Committee Member Executive Service CME Faculty Moderator / Chair Organizer of Events Membership Advocacy Other (Specify)

Describe your contribution to AGPJ activities.

SECTION 3 — CLINICAL CONTRIBUTION

Describe areas of clinical excellence or special interest.

Have you introduced improvements in patient care or practice systems?

SECTION 4 — COMMUNITY SERVICE

Describe community outreach activities:

Church outreach School health programmes Medical missions Public education initiatives Volunteer medical work

SECTION 5 — LEADERSHIP & PROFESSIONAL SERVICE

Leadership roles held:

Medical organizations Hospital committees National initiatives Professional advocacy

SECTION 6 — RECOGNITION RECEIVED

List awards or recognition received within the last year(if applicable).

SECTION 7 — DOCUMENT UPLOAD

Upload Updated CV (PDF) — optional, can be emailed

Max 10 MB

Upload Professional Photo — Required

Max 10 MB

SECTION 8 — DECLARATION

I confirm this information updates my AGPJ Professional Recognition Record. Date

Leave this field empty